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Thank you for your initial interest in becoming an Inland Empire Health Plan (IEHP) directly contracted provider. Prior to extending a contract, we must receive the following documents. 

 

PLEASE NOTE, IEHP is only accepting Vision Providers who meet the following exceptions through October 31, 2022:

  • Providers practicing in any of the CalAIM service area expansion territories effective January 1, 2022 (including formerly voluntary and excluded zip codes)
  • Providers filling positions that have been vacated in an existing practice
  • Providers transitioning from an existing group agreement to their own individual agreement
  • Providers being added to existing Vision groups

 

Please completely fill out all required documents and submit to contract@iehp.org.

 

Any delay in receiving the below stated documents will affect the effective date of the contract that will be mailed to you. 

 

2. Letter of Interest that outlines the following:

  • What Specialty/Services you are interested in contracting for
  • Facility locations(s)
  • National Provider Identifier (NPI) for each facility
  • Medi-Cal Provider information number (PIN)

3. W-9 Form (PDF)

  • A current Taxpayer Identification Number and Certification Form

5. Liability Insurance Certificate

  • Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence; and
  • Three Million Dollars ($3,000,000) aggregate per year for professional liability

6. Facility Business License - Faculty

7. Ownership Information (PDF)

  • Name, Title, and Percent of Ownership

 

Contracts Maintenance Request Form can be found here (PDF).

 

All documents should be e-mailed to contract@iehp.org.

 

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.