Get Uniformstamprenewalform2013.doc - Dshs State Tx

Filling out the Uniform Stamp Annual Renewal Form is a vital process for those authorized to administer yellow fever vaccinations in Texas. This guide provides clear steps to assist you in completing the form accurately and efficiently online.

Follow the steps to complete the Uniform Stamp Renewal Form online.

1. Click 'Get Form' button to access the form and open it in your editing tool.
2. Begin by entering your full name as the physician in the designated 'Physician Name' field.
3. Next, fill in your Texas Medical License Number in the corresponding field.
4. Provide your Stamp Number by filling in the required numerical sections.
5. Enter your facility's name in the 'Facility Name' section, followed by your complete address, including city, county, and zip code.
6. In the 'Facility Phone' and 'Facility Fax' fields, include the respective phone and fax numbers.
7. If applicable, enter your facility's website address.
8. Identify a contact person for your facility, providing their name along with a direct phone number.
9. Include a permanent email address for communication regarding your yellow fever account, preferably your own.
10. Report the total number of yellow fever vaccinations administered during the specified timeframe.
11. Review the agreement statements carefully and ensure you understand your responsibilities as an authorized vaccinator.
12. Sign and date the form to acknowledge your agreement.
13. Follow the instructions for payment, ensuring that 'ZZ304-008' and your name are included on the payment.
14. Mail the completed form along with the renewal fee to the Cash Receipts Branch at the Texas Department of State Health Services.
15. If you are not renewing, remember to mail the uniform stamp and the completed form to the Immunization Branch, as specified.
16. Once you have completed the form, save your changes, and you may choose to download, print, or share it as needed.

Complete your Uniform Stamp Renewal Form online today to ensure your continued authorization to administer yellow fever vaccinations!