PCP and Specialists

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 completely fill out all required documents.


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


New Contract










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

Existing Contract (Adding New Provider)


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

  • Provider Maintenance Request Form (PCP, OB/GYN, and Mid-Levels ONLY) can be found here (PDF).
  • Contracts Maintenance Request Form (Specialists ONLY) can be found here (PDF).
  • Individual W-9 form can be found here (PDF).
  • Direct Deposit Frequently Asked Questions can be found here (PDF).
  • National Plan & Provider Enumeration System (NPPES) Portal login: https://nppes.cms.hhs.gov/#/.
  • NPI Address Update Instructions can be found here (PDF).


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