• 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*
  • Will services be billed*
  • Start Date
     / /
  • End Date
     / /
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Fluent Language(s) Spoken*
  • Certified Language(s) Spoken*

  • Provider Information

  • License Issuance Date*
     / /
  • License Expiration Date*
     / /
  • Education & Experience
  • Attestation

  • Forms

  • E-Signature Form
  • Required Attachment Checklist for Providers
  • Required Attachment Checklist for MHRS and Other Qualified Providers
  • Browse Files
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  • Requestor / Supervisor Information

  • Requestor / Supervisor Information*

  • Roles / Permissions

  • County / Contractor*
  • Systems Access
  • Other Permissions

  • User Roles Descriptions

  • County Staff Roles
  • Contracted Provider Roles

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

  • Facility & Program Assignment

    • County Operated 
    • BHLinks
      Rows
    • Bon Air
      Rows
    • CARE Court
      Rows
    • Emergency Services
      Rows
    • Kerner
      Rows
    • Novato
      Rows
    • Hope
      Rows
    • Jail
      Rows
    • West Marin
      Rows
    • Road to Recovery
      Rows
    • YFS
      Rows
    • Contracted Providers 
    • Bi-Bett
      Rows
    • BACR
      Rows
    • Buckelew
      Rows
    • Center Point
      Rows
    • Child Therapy Institute of Marin
      Rows
    • Community Institute
      Rows
    • Cornerstone
      Rows
    • Center Point
      Rows
    • El Chante
      Rows
    • Family Spring
      Rows
    • HealthRight
      Rows
    • Integrated Community Services
      Rows
    • Marin Housing Authority
      Rows
    • MHASF
      Rows
    • MSM
      Rows
    • MTC
      Rows
    • North Marin Community Services
      Rows
    • Psynergy
      Rows
    • Quest Eagle
      Rows
    • Recover Medical Group
      Rows
    • Ritter Center
      Rows
    • Seneca
      Rows
    • Side by Side
      Rows
    • Waterfront
      Rows
    • Women's Recovery Services
      Rows
    • Other
      Rows

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

  • My electronic signature agreeing to the aforementioned is below.

  • Should be Empty: