Information Technology - InSyst Staff Master Worksheet Update
 
The completion of this form is required to update staff information. 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
Contact info of person submitting form
 
First Name: 
Last Name: 
Email: 
   
 
Staff Information
*All Fields in red are Required*
 
Simon Staff Number: 
   
First Name:   
   
MI: 
   
Last Name: 
   
Employee ID #:   
   
Termination Date:   
   
Phone:   
   
National Provider Identifier (NPI):   
   
Taxonomy:   
   
 
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:   
   
Professional Discipline 
(Select all that apply): 
 
  (For multiple selections, PC -hold down <ctrl> key
MAC-hold down <Command> key
   
Reporting Unit:   
   
 
   
Medicare Required Information
   
Will you be providing Medicare services? Yes No
   
Medicare Effective Date:   
Medicare Expiration Date:   
   
Birth Location - County: 
   
Birth State: 
   
Birth Country: 
   
University Attended: 
   
Degree Type: 
   
Date Degree Earned: