Direct Network PCP and Specialists 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. The L.A. Care Direct Network is our directly contracted network. Physicians can see L.A. Care members without being affiliated with an IPA.

Are you either an individual or group practice?

Individual

Group Practice

Select if you are either PCP, Specialist, Both (Multi-specialty group)

PCP

Specialist

Both (Multi-specialty group)

Practice Name

Office Administrator Full Name

Office Administrator Phone Number

Office Administrator Email Address

Provider Name

Requesting Individual (if different)

Legal Entity Name (as it appears on W-9)

Date

Licensure

DEA#

Date of Birth (DOB)

Specialties

Primary Specialty

Secondary Specialty

Type of Provider (Midlevel, DO,MD)

Number of Physicians

Tax Identification Number (TIN)

National Provider Identification (NPI)

Practice Address for location(s) in Los Angeles County

Other Address for location(s) in Los Angeles County

Phone Number

Fax Number

Hospital Surgery Center (if applicable)

Email Address

Languages

Certification (check all applicable boxes)

Medicare Certified

Medicaid Certified

CLIA Certified

Currently on the OIG exclusion list of DHCS suspended & ineligible list

If you are submitting a Letter of Interest for more than one provider or location, please attach a Roster with the following information (Individual Practitioner Name, Degree (MD, DO, PA, NP, etc.), Specialties, Primary, Secondary, CAQH # (if applicable), Type I (Individual, NPI #, List Each Practitioner’s Locations and Days and Hours of Operation at Each Location.

Roster

One file only.
100 MB limit.
Allowed types: jpg, jpeg, png, txt, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, zip.

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Direct Network PCP and Specialists Form

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