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IMPORTANT: Are you enrolled in Medi-Cal? Has your contact information changed in the past two years? Give your county office your updated contact information so you can stay enrolled. Go to benefitscal.com or call the Los Angeles County Department of Public Social Services at 1-866-613-3777

Ancillary Form

Thank you for your interest in becoming an L.A. Care Health Plan network provider.

All applicants are required to be Medi-Cal providers; this form is necessary to perform an initial assessment to confirm your eligibility for participation.
 

Are you Medicare Certified?: *

Are you Medicare Certified?

Are you Medicaid Certified? (Credentialing Requirement): *

Are you Medicaid Certified? (Credentialing Requirement)

Are you CLIA Certified?: *

Are you CLIA Certified?

Are you Currently on the OIG exclusion list of DHCS suspended & ineligible list?: *

Are you Currently on the OIG exclusion list of DHCS suspended & ineligible list?

More information

  • Files must be less than 25 MB.
  • Allowed file types: pdf doc docx xls xlsx.