Staff Master Worksheet

Staff Information

*All Fields in red are Required*

First Name:
MI:
Last Name:

Date of Birth:	(ex.16-APR-19XX)

Gender:

National Provider Identifier (NPI):

Taxonomy Code:

Ethnicity: (Select all that apply)		*Languages: (Select all that apply)
(For multiple selections, PC - hold down <Ctrl> key MAC - hold down <Command> key)		(For multiple selections, PC - hold down <Ctrl> key MAC - hold down <Command> key)

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 # 909-382-3073
	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)

Medicare Required Information

	Will you be providing Medicare services? Yes No
	Medicare Effective Date:	(ex. 07/19/2012)
	Medicare Expiration Date:	(ex. 07/19/2012)

	Birth Location - County:
	Birth State:
	Birth Country:
	University Attended
	Degree Type:
	Date Degree Earned:	(ex. 06-2004)

Departmental Information

Environment: (Select all that apply)

(For multiple selections,PC - hold down <Ctrl>key

MAC - hold down <Command> key)

InSyst Staff Master Worksheet