LAFP Member Information Update

First Name*

Last Name*

Title*

LAFP/AAFP ID*

Street Address:

Street Address (line 2):

City:

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Fax Number:

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Alternate Phone Number (NOT shared with the public):

Website URL:

Practice/Group Name:

Languages Spoken:

Hospital Affiliation:

Medicare Accepted: Yes No

Medicaid Accepted: Yes No

Workers Comp. Accepted: Yes No

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