County of Santa Cruz

Mental Health and Substance Abuse Services

MHE 87 Avatar User-Practitioner RequestForm Contractor Agency

Use this form if Avatar User and Practitioner access is needed. Use MHE 85 for Practitioner-Billing ID# Only.

(Do not use this form for County Employees. County Employees must useForm MHE 10)

Section 1: Completed by Contracting Agency

Add/NewComplete all of Section 1&2Change Complete Section 1&2 as appropriate Deactivate Section 1 as needed
For Change or Deactivate, briefly explain reason and be sure you fill-in 7, 7a. & 7b if deactivate √:
(Questions below must be answered in the far right column with Yes / No / NA / or written Answer)
1. Name of Agency
2. First Name
3. Last Name
4. Middle Name or Initial(optional)
5. Email Address
6. Access to ADP, MH or Both
7. Job Class/Function
7a. Supervisor of other staff? If YES, list first and last name of all staff this person supervises here: / NO YES
7b.If this is a deactivaterequestfor a supervisor, provide the first and last name of the Avatar user who will now supervise the staff listed above in 7a.
8. Name of another employee who does the same job
9. Any Specialty Access Required? i.e. reports, document scanning, transcribing, access to agency calendars, ability to reset user passwords, etc.
10. Name of Supervisor
11.Practitioner? (Yes or No) Yes, if seeing clients, writing progress notes, assessments in Avatar.
If “no” to Practitioner, complete the next line and submit the form.
If “yes” to Practitioner,complete Section 2 of this form and then submit.

Section 1 Completed By: Date Completed:

Notes/Comments:

Section 2: CoMPleted by Contracting Agency

1. Using calendar(s)? No Yes If yes, allow practitioner to see other practitioner calendars? No Yes
2a. Practitioner Gender:ChooseFemaleMaleOther 2b. Date of Birth:
3. Hire Date
4. Office Address, City, Zip Code
5. Office Phone Number
6. Ethnicity
7. Languages Spoken (other than English)
8. Individual NPI # (National Provider Indentifier) (obtain from NPPES website)
9. Individual NPI Taxonomy Code (obtain from NPPES website)
10. Social Security Number (required for DHCS Compliance/Auditing)
11. Licensed, Certified or Registered? (yes or no)
12. Practitioner Category for Coverage (can include more than one if practitioner has multiple licenses and certifications)
Continue to Page 2
SECTION 2 (CONTINUED): COMPLETED BY CONTRACTING AGENCY
13. License/Certification/Registration Authority (if other than State of California)
14. License/Cert/Reg Abbreviation and Number (i.e. LCSW 23432, CADC A0342323)
15. License/Cert/Reg Effective Date (from date)
16. License/Cert/Reg Expiration Date
Items 1718 to be answered with Yes or No and check ALL that apply for this practitioner
17. Does contract-provider staff need Waiver Application?
NO YES
If YES check one from below. The appropriate waiver will be sent to you as soon as possible:
IMFT ASW PCCI Psychologist Assoc. / 18.LOCAL Santa Cruz County Contract-providersONLY:
Does staff need an application for Mental Health
Rehabilitation Specialist (MHRS): NO YES
19. Program Association #1(refer to list of Programs for your Agency, or specify “All Programs”) / All Programs
Program Association #2
Program Association #3
Program Association #4
Program Association #5
Program Association #6
If more than 6 individual Programs, list the rest of them here and separate with commas

Sections 1 & 2 Completed By: Date Completed:

Notes/Comments:

Section 3: CoMPleted by County BH IS Staff

Avatar Username Avatar Practitioner ID # Date Entered:
Entered By Copy Routed to QI Contracting Agency Notified
Notes/Comments ______

MHE87 Avatar User-Practitioner Request Form Contractor AgencyRevised 12-01-2016