IEHP Patient Referral

IEHP Patient Referral
Patient's details
Patient's Name*

First NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Phone Number*
Please enter a valid phone number.
Patient's Date of Birth*
Patient IEHP ID: *
ICD-10 Code (ailments) (if you know them)
Important Note: To qualify for Personal Care and Homemaker services through the Inland Empire Health Plan (IEHP), you must begin the enrollment process for the In-Home Supportive Services (IHSS) program. If you need assistance with this process, please call IEHP Member Services at 800-440-4347. If you are already receiving IHSS, please indicate how many hours per month you were approved for.*
Tell us about the patient's current medical conditions.*
Should be Empty: