5508 Nar Forms Form Details

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QuestionAnswer
Form Name5508 Nar Form
Form Length2 pages
Fillable?Yes
Fillable fields20
Avg. time to fill out4 min 34 sec
Other names5508 nar forms printable, 5505 nar texas printable form, form 5508, 5508 nar form printable

Form Preview Example

Texas Department of Aging

Form 5508-NAR

and Disability Services

July 2014-E

Texas Nurse Aide Registry

Request for Reprint of Certificate and/or

Correction to Nurse Aide Registry Data

Please read all instructions before completing this form. Complete the following information.

Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.

Attach other documents as required below

Mail all documentation to Texas Nurse Aide Registry, P.O. Box 149030, MC E-414, Austin, TX 78714-9030. I request the following (check all that apply):

Correction to the Nurse Aide Registry database. The information provided below is correct.

Reprint of certificate for the following reason:

Misprint on certificate received (attach your certificate).

Name Change (Attach your certificate and a photocopy of your marriage license, divorce decree or other court order indicating a name change).

Original was lost, stolen or destroyed.

Other

(please specify)

Name of Applicant (Last, First, Middle)

 

 

 

 

 

Maiden Name (if applicable)

 

 

 

 

 

 

 

Social Security No.

 

Sex

 

Date of Birth (mm/dd/yyyy)

 

 

Male

Female

 

 

 

Mailing Address (Street or P.O. Box, Rural Route, Apartment Number, etc.)

 

 

County

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

 

Area Code and Telephone No.

 

 

 

 

 

 

 

By my signature, I certify that the information provided above is correct.

Signature – Nurse Aide

Date

Notes:

The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without required documents.

Tampering with or attempting to falsify a government record such as a nurses aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000 fine.

Form 5508-NAR

Page 2 / 07-2014-E

Address:

Applicant, did you:

sign the form?

specify why you are requesting reprint of certificate?

include a legible photocopy of your picture identification showing your birth date and the correct spelling of your name?

attach a photocopy of your marriage license, divorce decree or other court order for name change?

attach your certificate if request is for reprint?

Did you know?

You can verify certificate status by calling 1-800-452-3934.

You can download forms from our website: ht t p:/ / w w w .dads.st at e.t x.us/ pr ovider s/ nf / cr edent ialing/ nar / f or m s.ht m l

Mail the completed form to the Texas Nurse Aide Registry address below.

Texas Nurse Aide Registry

Mail Code E-414

P.O. Box 149030

Austin, Texas 78714-9030

credential@dads.state.tx.us

With a few exceptions, you have the right to request and be informed about the information that the Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact the Nurse Aide Registry at 512-438-2050.

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Type in the requested particulars in the segment Signature – Nurse Aide, Date, Notes: ● The Texas Nurse Aide, and by up to 10 years in prison and a.

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