KSTAR Best Practices in Communication Course Registration

Applicant Information
Name Name First Last
Primary Phone Primary Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Gender

Gender Male Female
Degree

Degree MD DO DPM RPh/Pharm D DDS PA NP DC Other Other
I am most interested in

I am most interested in Provider-provider communication Provider-patient communication Team communication Other – please identify Other – please identify
What is motivating you to take this Course (please check all that apply)

What is motivating you to take this Course (please check all that apply) Improve Patient Satisfaction Scores Referred by facility or third party Improve patient-centered interviewing skills Improve healthcare team communications Professional Development Other Other
Referral Source

Referral Source Self-referred, not referred by any third party Referred by a third party (includes Board Orders)
Third Party Referral Information (if applicable)
Referring entity
Name Name First Last
Phone Phone - ### - ### ####
Email
Payment Information

Credit/Debit Cards are accepted online through the Texas A&M payment gateway.

Or, mail a check to:
Texas A&M Rural and Community Health Institute
2700 Earl Rudder Freeway South, Suite 3000
College Station, Texas 77845
The check can be made out to KSTAR.

If you have any questions, contact Tracy Adams or Tammy Wagner at 979-436-0390.
Certification

I agree to participate in the KSTAR Medical Records Course and understand that all fees must be paid in advance before I am considered to be enrolled in the program.
I agree to hold harmless the KSTAR program employees and representatives from any liability resulting from or arising in connection with this agreement.

I agree to hold harmless the KSTAR program employees and representatives from any liability resulting from or arising in connection with this agreement. Agree
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Date Date / MM / DD YYYY

KSTAR Best Practices in Communication Course Registration

Applicant Information

Third Party Referral Information (if applicable)

Payment Information

Certification