Nominate A Provider

\Ver"i*ty\,n.; The quality or

state of being true,

factual or real

Verity HealthNet

P. O. Box 83578

Baton Rouge, LA 70884

225-819-1135

If you would like to nominate a provider for participation in the network, please submit the following information to Verity HealthNet. Upon receipt of this information, we will contact the provider for participation.

This online form is temporarily disabled. To nominate your provider, please print this form and fax it to Verity at 225-237-1624. Thank you for your patience.

Your First and Last Name:

Your Employer:

Your Area Code and Phone Number:

Your Email Address (to keep you updated):

Provider's Full Name:

Provider's Clinic Name (if applicable):

Provider's specialty:

Provider's Address:

Provider's City: State:

Providers Zip Code:

Provider's Area Code and Phone Number:

Comments:

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