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.
Contact Information
Contact info of person submitting form
First Name: 
Last Name: 
Staff Information
*All Fields in red are Required*
Simon Staff Number: 
First Name:   
Last Name: 
Employee ID #:   
Termination Date:   
National Provider Identifier (NPI):   
License/Certificate Information
License Status:   
If your "License Status" is Licensed or Pre-Licensed please complete the information below. Licensed staff must submit a copy of license to DBH-IT. Fax #: 909-890-0481
License #: 
Certified/Registered #: 
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: