Provider Application

Why join Healing Heroes Network? There are many members of our Armed forces who have given so much to protect our country and its way of life. These veterans are in urgent need of your expert medical support. Authorized Network providers include, but are not limited to: Medical, Dental, Vision, Acupuncture, Physical Therapy, Chiropractic and Hyperbaric services.

Provider's Name:*
Address*
City:*
State:*	ALASKA ALABAMA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
Zip:*
Phone:*
Fax:*
Email:*
Website:
Specialty (or area of practice):*
Professional designations:
YES I want to help these troops by donating services - Please have a representative contact me!

Disclosure: This is a preliminary questionnaire to initiate contact with a Healing Heroes Network representative. Completion of this form does not guarantee that the membership requested will be approved. Additional information may be required to determine eligibility.

Healing America’s troops, one Hero at a time