Letter of Interest — For Providers

Specialty category

Select all that apply to your group or practice.

Primary Care Specialty(ies) Hospital-Based

Group information

Group name*

Tax Identification Number (TIN)*

Organization NPI*

Contract contact name*

Contract contact title*

Contract contact email*

Contract contact telephone*

Credentialing contact name*

Credentialing contact title*

Credentialing contact email*

Credentialing contact telephone*

Provider information

If you have multiple providers, enter the lead provider here and attach a provider roster below.

Provider name*

Provider NPI*

CAQH ID number*

Specialty(ies)*

Specialty(ies) area of expertise

Hospital privileges

Ambulatory Surgery Center privileges Include dialysis facilities and endoscopy surgery centers, if applicable.

Dialysis facility(ies) you own List names, if applicable.

Endoscopy facility(ies) you own List names, if applicable.

Medi-Cal certified by PAVE?*

Yes No

Practice location

If you have multiple locations, enter the primary location here and attach a practice location roster below.

Practice location NPI*

Street address, including suite no.*

City, state, and ZIP code*

Practice email*

Practice phone*

Fax

Office hours*

Languages spoken*

Ages served*

Supporting documents

PDF, Word, Excel, or image files. Up to 25 MB total across all attachments.

Letter of Interest Include a description of specialized services and/or subspecialties, if applicable.

Curriculum Vitae (CV) — one per provider*

Current W-9 form* Must use the March 2024 version.

Current malpractice coverage*

California State Medical License(s)*

Provider roster (if multiple providers) Provider name, degree, specialty, individual NPI, license number, CAQH number, practice location(s), and all hospital and ASC privileges for each provider.

Practice location roster (if multiple locations)

Anything else?

Additional notes

Thank you — your Letter of Interest has been received.