Staff Member Information: Use Multiple Forms If Necessary

Please provide the following information for staff members who will require access to CareNet. You may also identify accounts that need to be deactivated for staff members who are no longer employed or do not require CareNet access. A separate form is needed for each satellite office location (based on SA license number). If a staff member works at more than one office for this agency, he/she must be listed for each office location. NOTE: Interns may have access to this agency’s CareNet website; however, SUD services will not be allowed to be entered into/billed in CareNet under the intern’s name.

Agency Information:

Program/Agency Name of Specific Site: / Person responsible for receiving CareNet Login information:
Phone:Extension: SA License #: / Name: / Email:

Staff Member Information:use multiple forms if necessary

Check Only One / Check Only One / Deactivate Former User Account
Last Name / First Name / Middle Initial
N/A of no MI / Date of Hire / Email address / If staff member had a previous login, include User ID below / Staff Member Title / See Page 2 for user type explanation
Clinical Listing Only* / CareNet User**
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern
Clinical Non-Clinical Intern

Authorized Signature: Title: Date:

Email: Processed by MSHN staff on: (For MSHN use only)

*Clinician Listing Only: the named staff member will not be granted access to CareNet; however, will be added to the Clinician Listing within CareNet (the Clinician Listing allows this agency to bill SUD services under this staff person’s name within the CareNet system). This person will not receive a login to your agency’s CareNet website.

**CareNet User: the named staff member will be granted access to your agency’s CareNet website; their job responsibilities may require them to access CareNet to add new cases, complete admission/discharge forms, request/review authorization requests, add services (SUD billing), edit existing client records, generate reports, etc. If this staff member is clinical, he/she will also be added to the CareNet Clinician Listing within the CareNet website automatically. Non-Clinical Staff and Interns will not appear on the CareNet Clinicial Listing.

Submit to r via fax at 517.574.4093