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Email Forms Manager

Texas Health Resources Health Information Exchange
612 E. Lamar Blvd.
Arlington, TX 76011

Please enter information below to request user access. If you would like to request access for multiple users, you may also fill out the Texas Health HIE User Access Form and email the completed form to Training must be completed prior to requesting user access. If you have not completed training, please go to training and tip sheets to review the training modules.

* Indicates required information
This Request is For * 

Clinic or Facility Name * 
Clinic or Facility Address * 
Address 2 
City * 
ZIP Code * 
First Name * 
Last Name * 
Middle Initial 
Title or Job Role * 
Email Address * 
Phone Number * 
List Physician(s) in Your Clinic 
Date Training Completed (MM/DD/YY) *  Calendar (mm/dd/yyyy)
Additional Information 
Do not include any personal health information or personal identification information not specifically requested in the form. 
Authentication * 

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