County of San Bernardino

Department of Behavioral Health

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 E-mail or call the Help Desk at (909) 884-4884 if you require assistance.

Update

Terminate (End employment)

Staff Information

*All Fields in red are Required*

	Simon Staff Number:
	First Name:
	MI:
	Last Name:
	Employee ID #:	(Non-County Staff enter N/A)
	Termination Date
	Phone:	(ex. 909-123-4567 ext. 1234)
	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 # 909-382-3073
	License #
	Certified/Registered #
	State:
	Renewal Date:	(ex. 30-SEP-2004)
	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)