The completion of this form is required to request an InSyst Staff Master Number for providing consumer services. 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.



Staff Information
    *All Fields in red are Required*
First Name:  
MI:  
Last Name:  
Date of Birth: (ex. 16-APR-19XX)
Gender:  
Taxonomy Code:  
Ethnicity: (Select all that apply) *Languages: (Select all that apply)  
 
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MAC - hold down <Command> key)
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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 # 909-890-0481
License #
Certified/Registered #
State:
Renewal Date:
National Provider Identifier (NPI)
Professional Discipline: (Select all that apply)
 
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MAC - hold down <Command> key)
 
   

Medicare Required Information

Will you be providing Medicare services?
(ex. 07/19/2012)
(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)    
   
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Position/Title:  
Employee ID #: (Non-County Staff enter N/A)
Start Date  
Status:  
Contact:  
Phone: (ex. 909-123-4567)
FAX:  
Primary Reporting Unit:  
Other RU's: