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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 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.

Contact Information

Contact information of person submitting form

* All Fields in Red are Required *

Staff Information

License/Certificate Information

(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

Departmental Information