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.

 DBH Home

  Update Terminate (End employment)

  Staff Information

            *All Fields in red are Required*

 

  Simon Staff Number:
 
 
 
   (Non-County Staff enter N/A)
  Termination Date
   (ex. 909-123-4567 ext. 1234)
  National Provider Identifier (NPI)
     
   

    License/Certificate Information

 
  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 # 909-38
2-3073
 
  Certified/Registered #
   
  (ex. 30-SEP-2004)
 

 
 

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

 MAC - hold down <Command> key)

 

    Medicare Required Information

      Yes      No
  (ex. 07/19/2012)
  (ex. 07/19/2012)
     
 
 
 
 
 
    (ex. 06-2004)