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

state of being true,

factual or real



Verity HealthNet

P. O. Box 83578

Baton Rouge, LA  70884


Provider Request Form


If you would like to apply for participation in Verity HealthNet, please submit the following information accordingly.  Upon receipt of this information, a provider packet will be sent to you for review.


Physician's Full Name or Facility Name:


Specialty or Facility Type:


Tax ID Number:


Contracting Contact Name: 


Contracting Contact AC and Phone Number:


Contracting Fax AC and Phone Number:


Provider Address:


Provider Address 2:


Provider City:                                    State:


Provider Zip:


Contact Email Address:







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P. O. Box 83578
Baton Rouge, LA  70884-3578
Copyright 2003 Verity HealthNet