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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

225-819-1135

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:

 

Comments:

 

 

 

 

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

      www.verityhealth.com