BlackNLA - Physician's Directory

African-American Physicians Additions Form

Type of Practice:
Name of Practice or Medical Group:
Prefix:
First Name:
Middle Initial
Last Name:
Suffix:
Username:
Password:
Specialty	Hold Ctrl to make multiple selections
Specialty Not Listed:
Hospital Affiliation:
Hospital Not Listed:
Address 1:
Address 2:
City:
State:	California
Zip Code:
Phone:
Fax:
E-mail:
Web Addresss:
Other Information

Please check all health plans that your office accepts:

Aetna	American Specialty Health Plan
Blue Cross of California	Blue Shield of California
Cal Farm	Care 1st Health Plan
Cigna	Community Health Plan
Denticare	Guardian
Health Net	Humana PPO
Inland Empire Health Plans	Inter Valley Health
Kaiser Permanente	Managed Health Network
Maxicare	Medi-Cal
Medicare	National Health Plans
One Health Plan of CA	Pacificare
SCAN/Smart Care Health Plans	Secure Horizons
Tower Health	UHP Healthcare
Unicare	United Healthcare
Universal Care	US Healthcare/Prudential
Ventura County Healthcare	Western Dental

Other Health Plan:
Other Health Plan:

Are you accepting new patients? Yes No