Community Behavioral Health Services - San Francisco Department ...

Hjfh;aksjd City and County of San Francisco Compliance/Provider Relations UnitDepartment of Public Health1380 Howard St., 2 nd FloorCOMMUNITY PROGRAMS San Francisco, CA 94103Credentialing and Verification for Staff IDLegibly PRINT OR TYPE responses. Your request will not be processed without an NPI number, supportingdocumentation, and both staff and supervisor signatures. Please submit your request in two (2) weeks in advance. NOBILLING IS ALLOWED until verification and credentialing is finalized. NO RETROACIVE BILLING WILL BE ALLOWED.NewUpdate Personal Info Update Program InfoUpdate License/Certificatio*ONLYfor UPDATES: include your Staff ID: _______ and fax with supporting documents to (415) 252-3032Personal InformationLast: __________________________ First: ________________________ MI: ___ Suffix: ____(Sr., Jr.)____-_____ DOB: ___/___/____ Gender: ____ Ethnicity: _________________________SSN: ____-Program Information MHcertification/registration)SA (for counselors who are certified or registered, you must provide a copy ofProgram Name: __________________________________ RU: _____________________Street Address: ___________________________ City: _____________________ State: ______ Zip Code:___________ Agency Phone: _____________ Agency Fax: ____________License/Certification InformationDegree: _______ License/Certification Type: ___________________________ License #: ____________Issued: ______________ Expiration Date: ___/___/____ DEA Number: ______________________ Medi-Cal PIN:________________________ MediCare PTAN: ___________________________________ NPI number:____________________ Taxonomy Code: ________________________Signatures and Contact InformationEmployee Signature: _________________________________________________ Date: ______________Employee Phone: ___________________ Employee E-mail: _________________________ Supervisor Name:_____________________ Supervisor Signature: ____________________ Date: _______Supervisor Phone: __________________ Supervisor E-mail: _________________________Compliance and Provider Relations Unit OnlyStaff ID #: ___________Credentialing Requirements Verified by: ____________________________________ Date: __________Languages (other than English)* Conversational Read Write Provide Services CertifiedInterpreter1. ________________________ 2. ________________________ 3. ________________________ 4. ________________________ *including American Sign Language (ASL)Submit completed form(s) and supporting document(s) to:Behavioral Health Information Systems1380 Howard StreetSan Francisco, CA 94103ATTN: AVATAR Accounts ManagerFAX: 415-252-3008State3