TPAPN Records Request Form

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TPAPN Records Request Form

Submit this form to receive the listed records.

Please provide the preferred method of delivery.
Nurse Name *
My TPAPN Case # *
Phone Number *
DOB *
I authorize TPAPN to send me a copy of the following below (checkmark all that apply):	Participation Agreement Medication Report Employer Quarterly Report Meeting Logs Self Reports Treatment Records Completion Letter Closure letter (if did not complete) All Drug Screens Other
If OTHER, explain

I would like to receive my documents by regular mail. My address is:
I would like to receive my documents by encrypt email. My email address is:
Submission Requirement *	By clicking this box, I acknowledge that I have submitted this records request.

Texas Peer Assistance Program for Nurses

Texas Nurses Foundation | 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin TX 78759

800.288.5528 | 512.467.2620 | tpapn@texasnurses.org