County of San Bernardino

Department of Behavioral Health

Information Technology

InSyst Staff Master Worksheet

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

Staff Information

*All Fields are Required*

	First Name:
	MI:
	Last Name:

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

	Gender:

	National Provider Identifier (NPI):

	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 Information

	License Status:
	Licensed staff must submit a copy of license to DBH-IT. Fax # 909-382-3073
	License #
	Certification #
	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

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

Departmental Information

Environment: (Select all that apply)

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MAC - hold down <Command> key)

	Position/Title:
	Employee ID #:	(Non-County Staff enter N/A)
	Start Date
	Status:
	Supervisor:
	Phone:	(ex. 909-123-4567 ext. 1234)
	FAX:
	Primary Reporting Unit:
	Other RU's: