myAvatar Staff Master Worksheet Update

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Information Technology - myAvatar Staff Master Update Worksheet

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 email or call the Help Desk at DBH.Helpline@dbh.sbcounty.gov or (909) 386-9730 if you require assistance.

Upon submission of the following Staff Master Worksheet online form/Staff Master worksheet update information online form, you are attesting the below referenced information is true and accurate including discipline, license/certification/registration/waiver status as well as all demographic information pertaining to provider. You also attest that by submission of this form, you understand submitting false information may lead to disciplinary actions in accordance with the code of conduct.

Please fill-out the Staff Master Worksheet as completely and accurately as possible. Errors or missing information will delay the approval process. Staff Master approvals will be sent up-to 10 working days after submission.

Reason for Submission:

Contact Information

Contact information of person submitting form

* All Fields in Red are Required *

First Name:

Last Name:

Email:

Staff Information

myAvatar Staff Number:

First Name:

Middle Initial:
Indicate your middle initial as it appears on your license/registration/certification.

Last Name:

Employee ID #:

Phone:

National Provider Identifier (NPI):

Taxonomy:

License/Certificate Information

License Status:

Professional Discipline:

Practitioner Credentials:
(Only applies to County Employees.
If Contract Provider, select N/A)

Medicare Required Information

Complete this section if you received a Medicare Approval Letter from DBH-Credentialing Unit.
If unsure, contact DBH-CredentialingUnit@dbh.sbcounty.gov

Will you be providing Medicare services?

Departmental Information

Environment:

Position/Title:

Employee ID #:

Position Start Date:

Status:

Supervisor Name:

Phone:

Fax:

Primary Reporting Unit:

Other Reporting Unit(s):

Comments: