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Get Excellent Provider Service Form - Texas Department Of State Health ...

We want to know the components of what made their visit with you so memorable. Please print this document and mail it to the ImmTrac office at P.O. Box 149347, Mail Code 1946, Austin, TX 78714- 9347 or save the document and e-mail it to ImmTrac.edu dshs.state.tx.us.. This form along with other documentation will go toward the Award of Excellence certificate. Your Information Last Name: First Name: Title: Provider/Facility/Site Name: Individual or Team of Immunizations Program Outreach Speci.

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