Prison Industry Authority
Provider Application
 
Please enter data in the following fields to request account approval from PIA:

Requirements: Please click here for Answer #2 on the PIA FAQ.

For address change requests, the new address must match the current professional license, Medi-Cal and vision plan provider records. Temporary status may be granted subject to DHCS review and approval.

Provider Type (Please check all that apply):
Provider No.:
List the Managed Care Vision Plan(s) (e.g., VSP):
Account Details:
Provider Name:
NPI Number:
Account Name:
Address 1:
Address 2:
City: State: Zip Code:
Telephone: Fax:
Email Address:
Confirm Email:
Contact Name:
Professional License Number: License Type:
Shipping Type: