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):
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
Provider No.:
Currently enrolled as a Medi-Cal Managed Care Plan Provider
List the Managed Care Vision Plan(s) (e.g., VSP):
Kaiser Permanente Providers:
Not a Kaiser Permanente Provider
Kaiser Permanente Southern California Region
Account Details:
Provider Name:
NPI Number:
Individual
Group
Account Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Telephone:
Fax:
Email Address:
Confirm Email:
Contact Name:
Professional License Number:
License Type:
Please Select
Optometrist
Physician
Optician
Shipping Type:
Select One
UPS
Other
Sacramento Overnight
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.