* 1. Area of Interest

* 2. Select a request

* 3. First Name:

* 4. Last Name:

and / or

* 5. Medical Facility/Special Care Center Name:

* 7. Street Address:

* 8. City:

* 9. State:

* 10. Zip Code

* 11. Contact Person:

* 12. Contact Person's E-Mail Address:

* 13. Phone Number:

* 14. Alternative Phone Number:

* 15. Fax Number:

* 16. NPI Number (If no NPI#, please type 9999999)

* 17. Additional NPI Number #1

* 18. Additional NPI Number #2

* Required - Must answer question.
For technical assistance, our Help Desk can be reached

Monday through Friday - 8:00 a.m. to 5:00 p.m.

Phone: 626-569-6630
E-Mail: CMSNetSupport@ph.lacounty.gov

T