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Area of Interest

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* 1. Area of Interest

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Select a request

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* 2. Select a request

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First Name:

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* 3. First Name:

Last Name:

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* 4. Last Name:

and / or
Medical Facility/Special Care Center Name:

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* 5. Medical Facility/Special Care Center Name:

Street Address:

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* 7. Street Address:

City:

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* 8. City:

State:

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* 9. State:

Zip Code

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* 10. Zip Code

Contact Person:

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* 11. Contact Person:

Contact Person's E-Mail Address:

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* 12. Contact Person's E-Mail Address:

Phone Number:

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* 13. Phone Number:

Alternative Phone Number:

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* 14. Alternative Phone Number:

Fax Number:

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* 15. Fax Number:

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NPI Number (If no NPI#, please type 9999999)

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* 16. NPI Number (If no NPI#, please type 9999999)

Additional NPI Number #1

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* 17. Additional NPI Number #1

Additional NPI Number #2

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* 18. Additional NPI Number #2

* Required - Must answer question.
For technical assistance, our Help Desk can be reached

Monday through Friday - 8:00 a.m. to 5:00 p.m.

Phone: 626-569-6630
E-Mail: CMSNetSupport@ph.lacounty.gov

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