11 Technology Drive

Irvine, CA 92618
Phone: (949) 923-3200
Fax:
(949) 923-3594

LETTER OF INTENT
Date
:
Physician/Practitioner
Name:

Contact Name:

Office Address:

Mailing
Address:

City, State,
Zip:

City,
Zip:

Telephone:

Telephone:

Fax:

Fax:

E-mail:

E-mail:

Group Name:

Office Hours:

Electronic Claims
Clearing House
or Direct
capabilities:

EHR System

(if applicable):

ABMS Certification Status:

Board Certified

Non Board Certified

Board
Eligible

(Date of Scheduled Exam)

National Provider Identification Number (NPI)

Individual
:

State,

Group
:

My Current Curriculum Vitae (C.V.) will be:

Attached

Faxed

E-mailed

to:

DLContractsCA@mhealth.com

As a provider with Monarch HealthCare, I would provide service to HMO AND (Select any of the
following):
CalOptima Medi-Cal
Yes
No

PPO Patients

All of the above

Have you ever been a Monarch HealthCare Provider in the past?

My primary specialty
is:

My secondary specialty
is:

The language(s) I speak:

The language(s) my office staff speak:

My Outpatient Surgery Center affiliation(s) is/are:

I have ownership in the following Outpatient Surgery Center(s):

I have Hospital Privileges at:

Anaheim Regional Medical

Center
Chapman Medical Center
Childrens Hospital at Mission
Childrens Hospital at Orange
Coastal
Communities
Hospital

Hoag Orthopedic Institute (HOI)

Placentia-Linda Hospital

Lakewood
Regional
Medical
Center
Long Beach Memorial Medical
Center
Los Alamitos Medical Center
Miller Childrens Hospital Long
Beach

Saddleback Memorial - Laguna Hills

Saddleback Memorial - San Clemente
St. Mary Medical Center
Western Medical Center - Anaheim

Fountain Valley Regional

Hospital
Hoag Hospital - Newport
Hoag Hospital - Irvine

Mission Hospital Regional Med

Ctr
Mission Hospital - Laguna Beach
Orange Coast Memorial Med
Center

Western Medical Center - Santa Ana

Applicant
Signature:
For Internal Use Only:
Screening
Date:

LOI Received Date:

Screening
Approval:
Screening

Form 3/1/2015