Update Provider Record

Please use this form to update information for any physician, allied providers, ancillary provider's hospitals or facilities currently in the Directory.
A Provider Relations representative will contact you to verify and update your Provider record.
Your Name and Phone Number are mandatory fields.
Please enter your email information if you would like to be contacted by email.

Email:      providerrelations@incentivehealth.org 
Toll Free:  833-796-0071 
Phone:      661-616-5447

Contact Information:

Your Name*:
Please enter Your Name.
Your Position:
Phone Number*:
Please enter Your Phone Number
Email Address:

Provider Information

Provider Name*:
( First Middle Last Degree )
Please enter the Provider Name.
Site Address*:
Please enter the Provider Address
Please enter the Provider City
Zip Code*:
Please enter the Provider Zip Code
Please enter the Provider Phone
Please enter the Provider Specialty
CA License Number / Type:
Accepting New Patients:
Additional Information

Hospital Affiliations, Languages, Board Certifications
Form Security
Although every effort is made to ensure complete and up-to-date provider information, this directory is subject to change without notice. To report provider listing inaccuracies, please contact Provider Relations by sending an e-mail to providerrelations@incentivehealth.org or by calling 833-796-0071 or 661-616-5447.
Please note that listing a provider in this directory does not mean services of the provider are automatically covered. Services must meet the coverage requirements and definitions of your specific plan.