Get Ca Dph Credentialing And Verification For Avatar Staff Id 2017-2025

This guide provides a straightforward approach to completing the CA DPH Credentialing and Verification for Avatar Staff ID form online. Follow these steps for a successful submission, ensuring that all necessary information is included for processing.

Follow the steps to complete your credentialing and verification form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate if this is a new request or an update by selecting the appropriate checkbox. Be specific whether you are updating your name, program, or license.
3. Fill in your personal information legibly, including your last name, first name, middle initial, suffix, social security number, date of birth, gender, and ethnicity.
4. For program information, select the relevant program type such as mental health or substance use disorder. If applicable, include a copy of your certification or registration.
5. Provide the program name, program code number, street address, city, state, zip code, agency phone, and agency fax.
6. Enter your professional license, registration, or certification information, including your degree, type, number, state issued, expiration date, DEA number, Medi-Cal PIN, Medicare PTAN, and NPI number.
7. Specify any additional languages spoken and whether you provide certified interpreter services.
8. Select your specialty by checking one box, choosing from child/adolescent, adults, substance use disorder, or other.
9. Sign the form by providing your signature, date, phone number, and email address. Ensure your supervisor also signs, dates, and provides their contact details.
10. Include the names and emails of any other staff members who should be notified of the employee’s Staff ID.
11. Once all sections are completed, save your changes, and prepare to submit the form as instructed.

Complete your CA DPH Credentialing and Verification form online today to ensure timely processing.