MSLA, A Medical Corporation

Become A Provider

MSLA, A Medical Corporation seeks qualified physicians and medical professionals to conduct IME's.

To become a MSLA provider, please complete the application below and send a copy of the following information:

Current copy of your professional licensure.
Copy of curriculum vitae.
Copy of current board certifications, if applicable. (A letter from board confirming certification is acceptable.)
Copy of fellowship certificate(s) if applicable.
Completed W-9 Form

Please send the above documents to the person and address listed below:

IME Credentialing
MSLA, A Medical Corporation
P.O. Box 93787
Pasadena, CA 91109

Telephone: 626-440-7001
Toll Free: 1-866-467-5222
Fax: 626-440-7003
E-mail: a.hernandez@mslaca.com

FILL OUT OUR ONLINE FORM (All fields except "Fax" required)
First Name:	Last Name:	Title:
Phone Number (include area code):	Fax Number (include area code):	E-Mail Address:
Medical License Number:	State of Licensure:	License Expiration Date (mm/dd/yyyy):
Specialty(ies)	Board Status:	Best time to call:

Become A Provider

FILL OUT OUR ONLINE FORM (All fields except "Fax" required)