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.
 
    
 
Staff Information
*All Fields in red are Required*
 
Simon Staff Number: 
   
First Name:   
   
MI: 
   
Last Name: 
   
Employee ID #:   
   
Email Address:      
   
Termination Date:   
   
Phone:   
   
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 #: 909-890-0481
   
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:   
Medicare Expiration Date:   
   
Birth Location - County: 
   
Birth State: 
   
Birth Country: 
   
University Attended: 
   
Degree Type: 
   
Date Degree Earned: