Get Uniform Stamp Replacement Form Physician Name - Texas ... - Dshs State Tx

This guide provides clear and concise instructions for completing the UNIFORM STAMP REPLACEMENT FORM for physicians in Texas. Follow these steps to ensure your form is filled out correctly and submitted without errors.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the UNIFORM STAMP REPLACEMENT FORM and open it in the designated editor.
2. Begin by filling in your name in the 'Physician Name' field at the top of the form.
3. In the next field, provide the complete name of the facility where your uniform stamp is registered.
4. Enter the full address of the facility, including the street address, city, and ZIP code.
5. Locate the 'Stamp Number' field and enter your unique stamp number. Ensure the format matches: 42 - ________ - _______________.
6. Input your Texas Medical License Number in the respective field provided.
7. Provide your telephone number in the specified format, including area code.
8. If applicable, enter your fax number in the designated field.
9. Identify the contact person for this replacement request and fill in their name.
10. Include the contact email address for follow-up communications.
11. Mark the reason for the stamp replacement by checking the appropriate option: lost, stolen, or stamp information illegible.
12. Enclose your $50.00 fee and ensure it is accompanied by the completed replacement form.
13. Sign and date the form in the designated areas to authenticate your request.
14. Ensure that the budget number and fund number 'ZZ304-008' are written on the payment to facilitate correct designation.
15. Mail the signed form and payment to the Cash Receipts Branch at the provided address in the guidelines.

Complete your UNIFORM STAMP REPLACEMENT FORM online today for a seamless replacement process.