Registration Form

AmeriHealth Caritas Louisiana is offering LOCUS Training to Healthy Louisiana providers.  Space is limited. 
Please register by Friday, September 16, 2016.

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* 1. Provider Name

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* 2. Provider Agency

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* 3. Address

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* 4. Phone Number

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* 5. Email Address

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* 6. License Type (Please put N/A if Not Applicable)

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* 7. License Number (Please put N/A if Not Applicable)

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* 8. NPI Number (Please put N/A if Not Applicable)

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