Thank you for your initial interest in becoming an Inland Empire Health Plan (IEHP) directly contracted provider.


PLEASE NOTE, IEHP is currently not accepting new:

  • DME
  • Hospice
  • Specialty Pharmacy
  • Clinical Laboratories
  • Non-Emergent Medical Transportation (NEMT)
  • Community Based Adult Services (CBAS) outside of the Inland Empire


Please check monthly for updates on Network Availability.


Prior to extending a contract, we must receive the following documents:


2. W-9 Form

  • A current Taxpayer Identification Number and Certification Form

3. Liability Insurance Certificate

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

4. Ownership Information (PDF)

  • Name, Title and Percentage of Ownership

5. Provider Accreditation Certificate

6. CMS/DHCS Passing Site Survey (Approval Letter)

  • Required for each facility

7. California State License (if applicable)

  • Required for each facility

8. Urgent Care Minimum Qualifications (if applicable)

9. Medi-Cal Number

  • Ancillary Providers need to successfully enroll in the State's Medi-Cal Program

10. Provider Acknowledgment of Receipt (AOR) 

  • IEHP is required by State and Federal regulators to maintain an AOR form on file for our Providers signifying your receipt and review of the Policy & Procedure manuals, including annual updates
  • Download the Provider AOR PDF form by visting the IEHP Provider Manuals page.

11. Electronic Remittance Advice (ERA) Form (PDF)

  • Ancillary Providers must complete the ERA form


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


Any delay in receiving the above stated documents will affect the effective date of the contract that will be mailed to you.  The contract collateral and other supporting contract documents should be e-mailed to


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