• STAFF USER ACCESS FORM

    The “Staff User Access Form” should be used anytime a Program is adding a new staff member or changing an existing staff member’s credentials and access to the BHRS Electronic Health Record. The staff member’s supervisor should complete all the below fields and upload the required documents. Please contact BHRSCredentialingPub@marincounty.gov with any questions.

  • Staff Information

  • Service Area*
  • Start Date
     / /
  • End Date
     / /
  • Format: (000) 000-0000.
  • Date of Birth*
     / /

  • Provider Information

  • License Issuance Date*
     / /
  • License Expiration Date*
     / /

  • Forms

  • Required Attachment Checklist for Providers
  • Required Attachment Checklist for MHRS and Other Qualified Providers
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Requestor / Supervisor Information

  • Roles / Permissions

  • County / Contractor*
  • Systems Access
  • Other Permissions

  • User Roles Descriptions

  • Please contact BHRSCredentialingPub@marincounty.gov with any questions.

  • Facility & Program Assignment

    • County Operated 
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    • Contracted Providers 
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    • Please contact BHRSCredentialingPub@marincounty.gov with any questions.

  • My electronic signature agreeing to the aforementioned is below.

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