User Enrollment Form

TxEVER USER ENROLLMENT FORM

* Indicates a mandatory field

* Type of User

Funeral Home and Director Information

* Funeral Home Name:

Funeral Home Name(Other):

* Texas Funeral Home License Number:

* Funeral Director First Name:

* Funeral Director Last Name:

* Texas Funeral Director License Number:

Medical Certifier Information

* Group, Facility, or Practice Name:

Group, Facility, or Practice Name(Other):

* First Name:

* Last Name:

* Texas Medical Board License Number: (Example: Y1234)

* Physician Title: (Example: M.D., D.O.)

Local Registrar Information

* Local Registrar First Name:

* Local Registrar Last Name:

* Local Registrar Office Name: (Example: Dallas County Clerk, Waco-McLennan County Public Health District, McLennan County JP 4)

* Registration District: (Example: City of Dallas, All of Dawson County, Precinct 4 & 5)

Justice of the Peace or Medical Examiner Information

* Judge or Head Medical Examiner First Name:

* Judge or Head Medical Examiner Last Name:

* M.E. Office/Justice of the Peace Seat Held (County and Precinct):

M.E. Office/Justice of the Peace Seat Held (County and Precinct)(Other):

* The date that the term expires:

Medical License Number:

Hospital User Information

* Facility Current Name:

Facility Current Name(Other):

* Hospital User First Name:

* Hospital User Last Name:

AOP Entity Code:

* Medicaid Facility License Provider Number: (Should be 9 digits)

* Local Registrar Office: (This is the office where you file your birth certificates)

Birthing Center User Information

* Facility Current Name:

Facility Current Name(Other):

* Birthing Center User First Name:

* Birthing Center User Last Name:

AOP Entity Code:

* Medicaid Facility License Provider Number: (Should be 9 digits)

* Local Registrar Office: (This is the office where you file your birth certificates)

Midwife Information

* Facility Current Name:

Facility Current Name(Other):

* Midwife First Name:

* Midwife Last Name:

AOP Entity Code:

* License Number: (Should be 9 digits)

Local Registrar Office: (This is the office where you file your birth certificates)

Telephone Number and Email Address

* Telephone Number:

* Email Address:

Physical Address Information of Office, Facility or Practice

*Address:

*State:

*City/Town:

Apt/Suite:

*County:

*Zip Code:

Mailing Address Information of Office, Facility or Practice

Mailing Address is the same as Physical Address?

Address:

State:

City/Town:

Apt:

County:

Zip Code:

Training and Enrollment Type

* Have you had any training regarding the TxEVER System?

* Is this a new enrollment or are you adding or changing a location to an existing account?

If this is NOT a new enrollment please provide your current location name

If this is NOT a new enrollment please provide your current location name(other)

If this is NOT a new enrollment please provide your TxEVER User ID

The TxEVER Administrator will be the person at your location who will receive the TxEVER instructions

TxEVER Facility Administrator First Name:

TxEVER Facility Administrator Last Name:

TxEVER Facility Administrator Telephone Number:

TxEVER Facility Administrator Email Address:

2nd TxEVER Facility Contact First Name:

2nd TxEVER Facility Contact Last Name:

2nd TxEVER Facility Contact Telephone Number:

2nd TxEVER Facility Contact Email Address:

If you have a Network Administrator at your facility, please complete the following information:

Network Support Person First Name:

Network Support Person Last Name:

Network Support Telephone Number:

Network Support Email Address:

* By typing your name in the following field you are acknowledging that you/your facility will adhere to the procedures stated in the User Agreement. Furthermore, it is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for acknowledging a form which contains a false statement is 2 to 10 years imprisonment and a fine of up to $10,000. (Health and Safety code, chapter 195, sec. 195.003)

* Your First Name:

* Your Last Name:

Please expedite this enrollment.