Congregate Living Health Facilities/Skilled Nursing Facilities Form

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.

Skilled Services: *

Skilled Services

LTC Services: *

LTC Services

Sub-Acute Services : *

Sub-Acute Services

On-site Dialysis : *

On-site Dialysis

Locked Facility: *

Locked Facility

Locked Units: *

Locked Units