Thank you for your interest in becoming an L.A. Care Health Plan network provider. This form is necessary to perform an initial assessment to confirm your eligibility for participation. Provider/Group Name Legal Entity Name (as it appears on W-9) Tax Identification Number (TIN) National Provider Identification (NPI) Provider Website URL Provider Practice Address Provider Practice Address Address 2 City/Town State/Province Enter the State/ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Provider Phone Number Provider Fax Number Provider Type Specialty Service Areas Other Address Email Languages Years of Experience Are you Medicare Certified? Yes No Are you Medicaid Certified? (Credentialing Requirement) Yes No Are you CLIA Certified? Yes No Are you Currently on the OIG exclusion list of DHCS suspended & ineligible list? Yes No Other Certifications Point of Contact Full Name Point of Contact Phone Number Point of Contact Email Address CAPTCHA Submit