Iehp transportation request form

***** FORM REQUIREMENTS ***** Complete Service Request Form in its entirety. Attach clinical notes, signed MD orders, and supporting documents. Please Note: request will be delayed if any required information is missing. Any request for Hospice authorization or Hospice services should be faxed to (909) 297-2513

Edit your transportation request form online. Type text, add images, blackout confidential item, add comments, highlights and more. 02. Sign is in a few button ... Abschicken move request form via email, linking, or fax. Thee can also download it, ship it or print it out. The plainest way to modify Transportation request form template in PDF ...Return this completed form via secure email to [email protected] with the applicable documents. (Allow up to five business days for referral processing and response.) Member ID: Member DOB (DD/MM/YYYY): ... Food Resources Transportation Resources Social Supports ResourcesAppointment of Representation (AOR) Request. Member 's Name: Member. ID Number: Health Plan Name: IEHP DualChoice (HMO D-SNP) Phone:1-877-273-IEHP (4347) Dear<<Member Name>>: We hope this letter finds you well. We are writing to let you know IPA got your request for coverage of an item, service, or drug.Which makes the iehp transportation request judicial binding? As of world ditches in-office work, the completion of paperwork see furthermore more happens get. The iehp transportation form isn’t an exemption. Working because it utilization electronic tools is different from doing so in the physical whole.Submit your written request in one of the following ways: By mail or in person to the county welfare department at the address shown on your NOA. By mail to the California Department of Social Services – State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430. By fax to (833) 281-0905.01. Edit your iehp prior authorization form online. Type text, add images, blackout confidential details, add comments, highlights and more. 02. Sign it in a few clicks. Draw your signature, type it, upload its image, or use your mobile device as a signature pad. 03. Share your form with others.As a reminder, all communications sent by IEHP can also be found on our Provider portal at: www.iehp.org > Providers > Plan Updates > Correspondences or www.iehp.org > For Providers > Plan Updates > Coronavirus (COVID-19) Advisory. If you have any questions, please do not hesitate to contact the IEHP Provider Relations Team at (909) 890-2054.Claims information regarding Medi-Cal rates, Medicare physician fee schedule, the Provider resolution dispute process and other health coverage FAQs are available for further review. Provider Services Phone. 909-890-2054. 1-866-223-IEHP (4347) Provider Services Email. [email protected].

Transportation Request Form (SNF & LTC) TODAYS DATE: * IEHP ID#: * NAME: Member Height: Member Weight: (Height & Weight needed only if Member is going by Wheelchair/ Gurney) SPECIAL NEEDS ... IEHP UM Transportation Department (909) 912-1049 within five (5) business days. Thank you!A complete request with clear medical justification is needed to ensure member safety and efficient delivery of pharmaceutical care. 2. Drugs (including physician-administered drugs) may be reviewed for coverage by submitting a Prescription Drug Prior Authorization Form or Referral Form. IEHP requires the request to be*Required Field TRANSPORTATION REQUEST FORM (HOSPITAL) Today’s Date: Discharge Date/Time: Member Name: IEHP Member ID: * Height: * Weight: Trach to Ventilator: Yes No Suctioning: Deep Mild Shallow Oxygen: Yes No ... Please fax request to IEHP UM Transportation Department (909) 912-1049 .80 INLAND EMPIRE HEALTH PLAN 10801 Sixth Street, Rancho Cucamonga, CA 91730 1-800-440-IEHP (4347) iehp. org We heal and inspire e human spirit. IEHP 2023 Quality Report: A Heart for Optimal CareProvider Appeal Request Process. 1. A Provider can submit an appeal request via phone, online portal, fax, mail or redirected from Utilization Management (UM). 1. By phone toll free at (800) 440-IEHP (4347) or (800) 718-4347 (TTY); 2.Enclosure: Transportation Request Form (SNF & LTC) P.O BOX 1800 Rancho Cucamonga CA 91729-1800 Phone: (951) 374-3441 Fax: (909) 912-1049 Visit our web site at: www.iehp.org ... Please fax request to IEHP UM Transportation Department (909) 912-1049 . Author: IEHP User Created Date:

Provide the time the request was received by your organization. Submit in HH:MM:SS military time format (e.g., 23:59:59). Note: If the request was received as a standard service authorization request, but later expedited, enter the time of the request to expedite the service authorization.As a L.A. Care Medi-Cal member, you are able to utilize transportation services to see your Provider and to obtain medically necessary covered services at no cost. L.A. Care will work with you and your Provider to find the transportation service that best fits your needs and to schedule a ride. Call L.A. Care Member Services at 1-888-839-9909 ...What manufacturer the iehp transportation request rightfully binding? Because the world ditches in-office jobs, the completion away paperwork more the continue what online. One iehp transportation form isn’t an exception. Working with it utilizing electronic toolbox is different out doing so in the physical world.Nonemergency ambulance for members, wherever they live. When asking for such transportation, you will need to complete the MassHealth Medical Necessity Form attesting to the member's condition and need for the requested transportation. Call the Mass Customer Service Center at (800) 841-2900 for a list of wheelchair van and …The purpose of this form is for physicians to communicate to ModivCareTM (formerly LogistiCare) specific transportation restrictions of a patient/member due to a medical condition. The restrictions and requirements stated on this form will be used by ModivCare to assign the best means of transportation for the patient/member.Complete background studies information. Complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462. MHCP Organization - Provider Enrollment Application (DHS-4016A) (PDF) Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS ...

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Please enter the access code that you received in your email or letter.Complete IEHP Area of Expertise Form online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. ... Getting care from a Specialist When the request is received by IEHP, a decision will be made within 5 business days for a regular referral. ... To set up transportation, call IEHP Transportation Department at 1-800-440-4347 ...with IEHP DualChoice about issues other than denied claims or services. IEHP DualChoice must respond to an expedited grievance within twenty-four (24) hours. To file an expedited grievance, you or your authorized representative should call, mail or fax your written grievance to: IEHP DualChoice. P.O. Box 1800 . Rancho Cucamonga, CA 91729-1800maintenance request. PLEASE NOTE THAT FOR PCP/OBGYN ( MD, DO, Extenders relating to PCP or OB/GYN contracts ) REQUESTS, YOU SHOULD CONTACT YOUR PROVIDER SERVICES REPRESENTATIVE AT 909-890-2054.

The Department of Veterans Affairs (VA) offers a wide range of services and benefits to veterans and their families. One of the most important tools available to veterans is the VA...Psychological/Neurological Testing Request Form 1. Name of Member: _____ 2. How long has the Member been in therapy: _____Disclosure Form (EOC/DF) July 1, 2019 - June 30, 2020 . ... you can request that we arrange transportation for you to see a ... please call Inland Empire Health Plan member services at . 1-800-440-IEHP (4347) (TTY . 1-800-718-4347) between 8 a.m. and 5 p.m., Monday throughCall IEHP's Automated Payment System, 1-855-433-IEHP (4347) (TTY 711), to make a payment by check, debit card, or credit card, or general purpose pre-paid debit card over the phone. Plan Premiums may be changed by IEHP effective January 1st of each year with at least 60If you are impacted by these events and need help with your durable medical equipment (such as wheelchairs, ventilators, oxygen monitors, etc.) call IEHP Member Services at 1-800-440-IEHP (4347), Monday-Friday, 7 a.m.-7 p.m. and Saturday-Sunday, 8 a.m.-5 p.m. TTY users should call 1-800-718-IEHP (4347) . If you need a medicine refill, go to ...Nonemergency ambulance for members, wherever they live. When asking for such transportation, you will need to complete the MassHealth Medical Necessity Form attesting to the member's condition and need for the requested transportation. Call the Mass Customer Service Center at (800) 841-2900 for a list of wheelchair van and ambulance providers.Edit, sign, and share iehp authorizes form online. No need to install software, just go to DocHub, and signature up immediately and for free. Back. Forms Library. Iehp authorization form. Get the up-to-date iehp authorised form 2023 now Geting Fill. 4.8 out of 5. 220 voice. DocHub Read. 44 reviews. DocHub Reviews. 23 ratings.Survey Incentive Request for Approval Form Page 3 MCP has determined how to assess the implementation process for the survey(s) MCP has determined how to assess the evaluation process for the survey(s) 11. Attached to the request is a draft copy of the survey or sample questions 12. Additional comments (if any):Edit, sign, and share iehp transportation request buy. No need to install program, just go to DocHub, and sign up instantly and for free. Home. Shapes Library. Iehp phone number. Get the up-to-date iehp transportation request 2024 now Get Form. 4.8 out of 5. 117 vootes. DocHub Reviews. 44 reviews. DocHub Criticisms. 23 ratings. 15,005 ...Submit your written request in one of the following ways: By mail or in person to the county welfare department at the address shown on your NOA. By mail to the California Department of Social Services – State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430. By fax to (833) 281-0905.*Required Field TRANSPORTATION REQUEST FORM (HOSPITAL) Today’s Date: Discharge Date/Time: Member Name: IEHP Member ID: * Height: * Weight: Trach to Ventilator: Yes No Suctioning: Deep Mild Shallow Oxygen: Yes No ... Please fax request to IEHP UM Transportation Department (909) 912-1049 . Do whatever you want with a IEHP - Transportation Request Form (Hospital): fill, sign, print and send online instantly. Securely download your document with other editable templates, any time, with PDFfiller. No paper. No software installation. On any device & OS. Complete a blank sample electronically to save yourself time and money. Try Now!

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Enclosure: Transportation Request Form (Hospital) P.O BOX 1800 Rancho Cucamonga CA 91729-1800 Phone: (951) 374-3441 Fax: (909) 912-1049 Visit our web site at: www.iehp.org ... Please fax request to IEHP UM Transportation Department (909) 912-1049 . Author: IEHP User Created Date:1. Members, their authorized representative, or their Provider, may make a direct request to IEHP or the Member's IPA for COC. 2. IEHP and its IPAs accept requests for COC over the telephone and do not require the requestor to complete or submit a paper or computer form if the requester prefers to request telephonically.The purpose of this form is for physicians to communicate to LogistiCare specific transportation restrictions of a patient/member due to a medical condition. The restrictions and requirements stated on this form will be used by LogistiCare to assign the best means of transportation for the patient/member. In an efort to be most eficient with ...The following tips can help you fill in IEHP Transportation Request Form (SNF & LTC) quickly and easily: Open the template in the full-fledged online editing tool by clicking on Get form. Fill out the requested boxes which are yellow-colored. Hit the arrow with the inscription Next to move on from box to box.Complete IEHP Area of Expertise Form online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. ... Getting care from a Specialist When the request is received by IEHP, a decision will be made within 5 business days for a regular referral. ... To set up transportation, call IEHP Transportation Department at 1-800-440-4347 ...The transportation request form template is very handy for all logistics companies or others looking for a way to increase the efficiency of managing the transportation requests coming from their customers. Just customise this free template with the fields you need, with a simple drag-and-drop form builder, change the theme or upload some ...Print, sign, and share iehp transportation request online. No need toward install software, just walk to DocHub, and sign up instantly and for get. Home. Forms Library. Iehp transportation request. ... Amend your iehp transportation form online. Type print, add images, blackout confidential details, add comments, highlights and find. 02. Sign ...Page1of2 New 08/13 Form 61‐211 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: Inland Empire Health Plan Plan/Medical Group Phone# :( 888) 860-1297 Plan/Medical Group Fax# :(909) 890-2058 Instructions: Please fill out all applicable sections on both pages completely and legibly.

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Page1of2 New 08/13 Form 61‐211 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: Inland Empire Health Plan Plan/Medical Group Phone# :( 888) 860-1297 Plan/Medical Group Fax# :(909) 890-2058 Instructions: Please fill out all applicable sections on both pages completely and legibly. The biggest public not-for-profit Medicaid/Medicare program in the Inland Empire, with affordable and free health insurance. TRANSPORTATION ASSISTANCE REQUEST: For urgent requests, please contact the UPHP Transportation Department at 1-800-835-2556 (TTY: 711), Monday through Friday from 8 a.m. to 5 p.m. Eastern Time. The call is free. ... Please submit a separate request form for each provider and visit type.I am aware that I may stop (revoke) this appointment at any time by sending a written request to IEHP at: Inland Empire Health Plan | Attn: Member Services P.O. Box 1800 | Rancho Cucamonga, CA 91729 Fax: 909-890-5877 | Email: [email protected] Empire Health Plan Legal Department. 10801 Sixth St. Rancho Cucamonga, CA 91730. Email: [email protected]. Fax: 909-477-8578. Authorization of Release (PDF) - This form authorizes IEHP to use and disclose Protected Health Information.IEHP Direct Provider Network. • Your IEHP Network Participation Form will be reviewed and a response will normally be mailed within two weeks. • IEHP will review your request to ensure you meet initial participation criteria, including maintaining admitting privileges at an IEHP Network Hospital. • Please type or print legibly.Catalog. Transportation Proposal Template. IEHP Transportation Request Form (SNF & LTC) 2017-2024 free printable template. Get Form. Show details. pdfFiller is not affiliated with any government organization. 4,4. 98,753 Reviews. 4,5. 11,210 Reviews. 4,6. 715 Reviews. 4,6. 789 Reviews. Get, Create, Make and Sign.Transportation request form FAQs: Let us transport you to easier workflows. Managing requests can be time-consuming. We’ve made light work of it. Our responses are easy to track and manage in your Typeform workspace. Staying on top of requests shouldn’t be difficult. You can trigger live notifications whenever you receive a transportation ...909-890-2054. 1-866-223-IEHP (4347) Provider Services Email. [email protected]. Get access to Provider contracting forms to join the IEHP network. ….

Edit, sign, and share iehp authorized form online. None need in install software, just go to DocHub, and sign up instantly and for free. Home. Forms Library. Iehp authorization fill. Get which up-to-date iehp authorized make 2024 now Get Form. 4.8 out on 5. 220 votes. DocHub Reviews. 44 reviews. DocHub Reviews. 23 classification.Edit, sign, and share iehp transportation request online. No need to install software, just go to DocHub, and sign up instantly and for free. House. Forms Library. Iehp transportation please. Get the up-to-date iehp transportation request 2023 now Get Form. 4.8 out starting 5. 117 votes. DocHub Reviews. 44 reviews. DocHub Reviews. 23 …We would like to show you a description here but the site won't allow us.Appointment of Representation (AOR) Request. Member 's Name: Member. ID Number: Health Plan Name: IEHP DualChoice (HMO D-SNP) Phone:1-877-273-IEHP (4347) Dear<<Member Name>>: We hope this letter finds you well. We are writing to let you know IPA got your request for coverage of an item, service, or drug.TAP do të mbështesë një gamë të gjerë projektesh për komunitetet nëpër të cilat kalon gazsjellësi. Programi i Investimit Social dhe Mjedisor (SEI) i TAP-it, e tejkalon shumën prej 14 milion €. Projektet do të përqendrohen në: Cilësinë e jetesës së komuniteteve vendase, duke e vënë theksin në rehabilitimin e shkollave.Still have questions? Provider Services Phone. 909-890-2054. 1-866-223-IEHP (4347) Provider Services Email. [email protected]. IEHP strongly encourages communication between treating specialists and referring Providers, to support coordination and integration Of care efforts for our Members. Therefore, we request that a Release Of Information be signed by our Member and included With this form, Which Will allow the maintenance request. PLEASE NOTE THAT FOR PCP/OBGYN ( MD, DO, Extenders relating to PCP or OB/GYN contracts ) REQUESTS, YOU SHOULD CONTACT YOUR PROVIDER SERVICES REPRESENTATIVE AT 909-890-2054.Get the up-to-date iehp transit request 2023 now Receive Form. 4.8 out of 5. 117 votes. DocHub Read. 44 reviews. DocHub Reviews. 23 ratings. 15,005. 10,000,000+ 303. 100,000+ users . Here's how it mill. 01. Edit your iehp transportation fashion online. Type text, add images, blackout intimate details, add comments, highlights both more.Who to Call with Questions on IEHPs PDR Process. Contracted providers may visit our online secure provider portal at www.iehp.org for more information. Providers may also call the IEHP Provider Call Center at (909) 890-2054 or (866) 223-4347 Monday-Friday, 8:00 am to 5pm PST. Iehp transportation request form, As a L.A. Care Medi-Cal member, you are able to utilize transportation services to see your Provider and to obtain medically necessary covered services at no cost. L.A. Care will work with you and your Provider to find the transportation service that best fits your needs and to schedule a ride. Call L.A. Care Member Services at 1-888-839-9909 ..., Emergent Medical Transportation (NEMT) service requests, and Non‐Medical ... •Facility will provide IEHP with timely and complete forms (i.e. Service Request Form), as needed. •IEHP will provide timely review and approval of skilled or custodial days, based on medical necessity. •IEHP will provide timely review and approval of ..., Get and up-to-date iehp transportation request 2023 now Get Form. 4.8 out of 5. 117 voice. DocHub Reviews. 44 reviews. DocHub Critical. 23 ratings. 15,005. 10,000,000+ 303. 100,000+ users . Here's how it our. ... Adhere into the instructions below in fill exit Iehp transportation request online quickly and easily:, Contracts Maintenance Request Form (PDF) W-9 Form (PDF) (Remittance advice address change) Medi-Cal Number (Physicians should be enrolled in the State's Medi-Cal Program) Frequently Asked Questions (FAQs) 1. What is IEHP? IEHP stands for Inland Empire Health Plan. IEHP is a not-for-profit health plan that serves over 1,000,000 Members in public ..., IEHP Direct Provider Network. • Your IEHP Network Participation Form will be reviewed and a response will normally be mailed within two weeks. • IEHP will review your request to ensure you meet initial participation criteria, including maintaining admitting privileges at an IEHP Network Hospital. • Please type or print legibly., To coordinate transportation, call the IEHP Transportation Call Center at 1 (800) 440-4347. El Sol is offering free rides through Uber to a vaccination site near you. To request a ride, call El Sol's COVID-19 helpline at (800) 901-5541. The helpline is available Monday to Friday from 9 a.m. to 5 p.m. Victor Valley Transit Authority is ..., Still have questions? Provider Services Phone. 909-890-2054. 1-866-223-IEHP (4347) Provider Services Email. [email protected]., 9 Jan 1180 — Most providers request authorization with an Treatment Authorization Request (TAR) (form 51-8). Long Term Take (LTC) and Subacute Care providers ... Provider Manuals IEHP care Policies and Proceedings that are shared with Providers till complies with State, Federal regulations and contract-related requirements., CONTRACT MAINTENANCE REQUEST FORM ... Please email this form to [email protected] upon completion. Title: Microsoft Word - 20181128 - Contract Maintenance Request Form Author: i4356 Created Date: 4/27/2021 10:52:59 AM ..., Pharmacy Drug Management Program for Pain (PDF) Quantity Limit Policy (PDF) Information on this page is current as of March 1, 2024. Provider Services Phone. 909-890-2054. 1-866-223-IEHP (4347) Provider Services Email. [email protected]., TRANSPORTATION REQUEST FORM (SNF & LTC) IEHP Member ID: DC Date and Time: Member Name: *Height: *Weight: Trach to Ventilator: Yes No . Suctioning: Deep Mild Shallow . Trach to Oxygen: Yes No . Liter Flow: FIO2: Trach to Room Air: Yes No . Oxygen: Yes No . Comments: *Height and weight are required if Member is transported via wheelchair or gurney., PCPs, BH, & BHT Providers IEHP - Provider Relations December 29, 2023. NEW! Referral Request Process Updated. Effective January 1, 2024, the Referral Request process for all (Medical, Behavioral Health/Behavioral Health Treatment and Hospice) referral types will be updated. From the left column, click the Referrals tab and then Request., PLEASE COMPLETE ALL SECTIONS, SIGN, AND RETURN THIS FORM TO: Inland Empire Health Plan | Attn: Member Services P.O. Box 1800 | Rancho Cucamonga, CA 91729 Fax: 909-890-5877 Email: [email protected]. FOR INTERNAL USE ONLY Authorization contains Privileged and Con dential Information. Page 2 of 2., Use signNow to e-sign and share Iehp transportation request form snf for collecting e-signatures. be ready to get more. Create this form in 5 minutes or less. Get Form. Video instructions and help with filling out and completing Iehp Transportation Number Form. Find a suitable template on the Internet. Read all the field labels carefully., Get the up-to-date iehp transportation request 2023 instantly Get Form. 4.8 out of 5. 117 votes. DocHub Reviews. 44 reviews. DocHub Reviews. 23 ratings. 15,005. 10,000,000+ 303. 100,000+ users . Here's how it works. 01. Cut insert iehp cell number online ... How to modification Iehp transportation request in PDF format online. 9.5., Complete IEHP Area of Expertise Form online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. ... Getting care from a Specialist When the request is received by IEHP, a decision will be made within 5 business days for a regular referral. ... To set up transportation, call IEHP Transportation Department at 1-800-440-4347 ..., Survey Incentive Request for Approval Form Page 3 MCP has determined how to assess the implementation process for the survey(s) MCP has determined how to assess the evaluation process for the survey(s) 11. Attached to the request is a draft copy of the survey or sample questions 12. Additional comments (if any):, Address: IEHP DualChoice Grievance Department P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Fax Number: (909) 890-5748 You may also ask us for an appeal through our website at www.iehp.org Expedited appeal requests can be made by phone at 1-877-273-IEHP (4347). Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If ..., Use of this model form by an enrollee, representative or prescriber is optional. Plan sponsors must accept any written request for a coverage determination, including any request submitted on this model form. If this model form is used, the Medicare drug plan may require additional information or documentation to support the request., Member Incentive Program Request for Approval Form Page 3 MCP has determined how to assess the evaluation process for the MI Program 11. Additional comments (if any): _____ 12. MCP Contact Person (person submitting the form and/or person responsible for the program):, The purpose of this form is for physicians to communicate to ModivcareTM specific transportation restrictions of a patient/member due to a medical condition. The restrictions and requirements stated on this form will be used by Modivcare to assign the best means of transportation for the patient/member., the revised Transportation Request Form (Hospital) when scheduling transportation for IEHP Members. The attached form has been updated to include the …, To learn more about Behavioral Health at IEHP, visit our Behavioral Health Section at www.iehp.org. Please feel free to contact Provider Services at (909) 890-2054 or e-mail our Contracts department at [email protected] Yours in good health, Behavioral Health Department, Mailing address: 106 Jefferson St, Suite 300 San Antonio, TX 78205 Email address: [email protected] Fax: 888-432-0026. Please remember to call Saferide at 1-855-932-2318 before your ITP drives you to any appointments in order to book your appointments in our system. You can request claim forms through any of the above contacts., Attachment 25 - IEHP Universe Standard Service Auth Request MSSAR Data Dictionary Column ID Field Name Field Type Field Length Description A Member First Name CHAR Always Required 50 First name of the member BMember Last NameCHAR Always Required 50 Last name of the member CMember IDCHAR Always Required 20 Medicare Beneficiary Identifier (MBI) used to identify the member., The children going to the kindergarten in the village of Dushnik used to cram into two classrooms part of the local elementary school. The facilities were far from being suitable …, Inland Empire Health Plan Member Handbook What you need to know about your benefits 2022 Combined Evidence of Coverage and Disclosure Form (EOC/DF) Effective January 1, 2022 Kaiser Foundation Health Plan, Inc. Southern California Region, Revise, print, and release iehp transportation request online. Negative need to install software, just go toward DocHub, and sign up instantly and for free. Home. Forms Library. Iehp transit request. ... Edit your iehp transports form internet. Type text, add images, blackout confidential details, add your, underlines and more. 02. Sign thereto ..., We would like to show you a description here but the site won’t allow us., Transportation Request Form (SNF & LTC) TODAYS DATE: * IEHP ID#: * NAME: Member Height: Member Weight: (Height & Weight needed only if Member is going by Wheelchair/ Gurney) SPECIAL NEEDS ... IEHP UM Transportation Department (909) 912-1049 within five (5) business days. Thank you!, According to the IRS, the W-9 form supplies a Taxpayer Identification Number to anyone who is required by law to file an “information return” concerning the taxpayer. Taxpayers giv..., by IEHP and/or Medi-Cal and are unavailable as a benefit to me. I understand that I am under no obligation to purchase any non-covered service or that in requesting such services or materials, I accept full responsibility of payment for all charges as indicated above. This waiver does not apply to any IEHP/Medi-Cal covered benefits., maintenance request. PLEASE NOTE THAT FOR PCP/OBGYN ( MD, DO, Extenders relating to PCP or OB/GYN contracts ) REQUESTS, YOU SHOULD CONTACT YOUR PROVIDER SERVICES REPRESENTATIVE AT 909-890-2054.