TxTRA Change of Address Form

CHANGE OF ADDRESS FORM

Have you found a mistake in this directory or have you moved?

If there are any changes that need to be made in the directory listings, please fill out the entire form and indicate with an "x" beside the information which is new and/or needs to be corrected.

Click on the Submit Form button below to email the changes to Joyce Ritter, RHIA, CTR
JRitter@harringtoncc.org.

Instead of emailing the form, it may also be printed and faxed to: 806-355-7290

Name:
Institution/
Company:
Address:
Address (cont.):
City:
State:
Zip:
Phone:
Fax:
E-mail Address:
Other:
Home Address:
City:
State:
Zip:
 Use Home address for correspondence?
 Use Office address for correspondence?

Comments:

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