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THSA Collaboration Council Application
*
1.
Contact Information
(Required.)
Full Legal Name
Preferred Name
Physical Home Address (not required)
City, State, Zip (not required)
Mailing Address
City, State, Zip
County
Work Telephone
Home Telephone (not required)
Cell phone
Preferred Email Address
Secondary Email Address:
*
2.
Employment Information
(Required.)
Employer
Employer's Address
Job Title
Health Care Sector
Job Description
*
3.
Interest in Health Information Exchange
(Required.)
What business or professional interests do you have in health information exchange?
Please state your reason for submitting an application for this council:
*
4.
By checking this box, I hereby promise that I am joining this council for the purpose of collaboration, and that I will be respectful of all council members’ thoughts and opinions. I further promise that I am not joining the council for any purpose that is adverse to the THSA’s stated purpose under Chapter 182 of the Texas Health & Safety Code. I recognize that I may be removed from the council for violating these promises.
(Required.)
Agree
Disagree
Current Progress,
0 of 4 answered
