Staff Master Banner

The completion of this form is required to request an InSyst Staff Master Number for providing consumer services. Submit this form to DBH Information Technology by using the submit button at the bottom of this page. You may email or call the Help Desk at (909) 884-4884 if you require assistance.

Please fill-out the staff master worksheet as completely and accurately as possible. Errors or missing information will delay the approval process. Staff master approvals will be sent up-to 10 working days after submission.


Contact Information

Person submitting form

First Name:  
Last Name:  

Confirmation email will be sent

(Enter your email address)


Staff Information

** All Fields in red are Required **

First Name:  
MI:  
Last Name:  
Date of Birth: (ex. 01/01/2000)
Gender:  
Taxonomy Code:  
Ethnicity: (Select all that apply) Languages: (Select all that apply)  
 
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MAC - hold down <Command> key)
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MAC - hold down <Command> key)
 

License/Certificate Information

License Status:  
If your License Status is "Pre-Licensed/Registered" or "Licensed/Certified/Waivered",
please complete the fields below and send a copy of your license, registration, certification or waiver to DBH via email at: DBHIT@dbh.sbcounty.gov.
License #  
Certified/Registered #  
State:  
Renewal Date:  
National Provider Identifier (NPI)  
Professional Discipline: (Select all that apply)  
 
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MAC - hold down <Command> key)
 

Medicare Required Information

Will you be providing Medicare services?  
Medicare Effective Date: (ex. 01/01/2000)
Medicare Expiration Date: (ex. 01/01/2000)
Birth Location - County:  
Birth State:  
Birth Country:  
University Attended  
Degree Type  
Date Degree Earned: (ex.01-2000)

Departmental Information

Environment: (Select all that apply)  
 
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Position/Title:  
Employee ID #: (Non-County Staff enter N/A)
Start Date (ex. 01/01/2000)
Status:  
Supervisor Name:  
Phone: (ex. 909-123-4567)
Fax: (ex. 909-123-4567)
Primary Reporting Unit:  
Other RU's: