Ark-La-Tex Health Services

Provider Information

Name *

Group or Individual TIN *

Practice / Facility Name

Specialty

Attendee Name

Title

Attendee Name

Title

Attendee Name

Title

Address *

City *

State *

Zip/Postal Code *

Email *

Daytime Phone *

Alternate Phone

Notes

Payments *

How many are you paying for? Please note, you only need to pay for Non Ark-La-Tex Health Network Members

2025 Insurance Symposium - Non-Ark-La-Tex Health Network Members $50

$0 TOTAL:

Refund Policy:

If an initial applicant is not approved for participation as a participating provider, the initial participation fee will be refunded, less operational expenses incurred.
Annual participation fees paid by current ALT providers will not be refunded under any circumstances.

Provider Information

Refund Policy:

Service Area