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Form 2 Revised College Station Texas: What You Should Know

A) Personal Information: Title: PACT Date: 10/16/08 Signature: PATRICK MERRICK (Signed by the Secretary) Personal Information: Title: PTA Date: 10/16/08 Section II—Section I: Section II — Section I: 10/26/09 PTA /PTFE: PTA Section I: 10/26/09 Personal Information: Title: HISPANIC PTA & PT FMI: I hereby certify that I am a foreign national with temporary resident status in the United States. This information is current as of the date of the registration form for this position. Section I — Section II: Section I — Section II: 10/31/09: PATRICK MERRICK Personal Information: Title: TEXAS TECH Personal Information: Title: TRANSFERRED TUBERCULOSIS (TE) PTA: TTC I certify that I have worked for this company for more than one year and have worked on at least two projects. If you are selected as the new Medical Records Supervisor for the Westlake School District, you will be notified directly using a letter from the principal, followed by notice in the student newspaper in your high school. We are looking forward to working with you! For more information go to: and Schools must send the new Application for the Certification of Personal Health Information (PHI) in 10, 11, or 12-month increments to the Texas Department of State Health Services (DSS) on a form by August 1, 2011. The form is available at the following address. Texas Department of State Health Services P.O. Box 2089 Austin, Texas 78 If schools complete the application for the Certification of Personal Health Information (PHI) using the Electronic Medical Records (EMR) System's version of this form, they will receive a temporary authorization for a new employee.

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