Please enter data in the following fields to request account approval from PIA:
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):
Currently enrolled as a Medi-Cal Provider with the Department of Health Care Services
Currently enrolled as a Medi-Cal Ordering/Referring/Prescribing Provider
Currently enrolled as a Medicare Provider
Currently enrolled as a Medi-Cal Managed Care Plan Provider
List the Managed Care Vision Plan(s) (e.g., VSP):
Professional License Number:
Stat Delivery Services
I declare under penalty of perjury under the laws of the State of California that the foregoing information is true to the best of my knowledge and belief.