Provider Interest Form

Thank you for your interest in joining HPSM’s provider network. Please complete and submit the interest form below to be contacted by the HPSM Provider Services team about credentialing. Submitting this form does not automatically enter a provider into the credentialing process. HPSM staff will assess network need and respond accordingly via email.

Please ensure you are also contracted through Medi-Cal before contacting HPSM. Visit the DHCS Provider Application and Validation for Enrollment (PAVE) page or contact PSinquiries@hpsm.org for more information.

First name:

Last name:

Email:

Phone:

Group or Facility (if applicable):

NPI:

Provider type:

Services offered:

Are you Medi-Cal enrolled? Yes No

Providers must be enrolled with Medi-Cal to join the HPSM network. Visit the DHCS Provider Application and Validation for Enrollment (PAVE) page for more information.

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Provider Interest Form