Get To Download The Focus Access Request Form (adobe Pdf) - Mccmh

This guide provides a clear and user-friendly approach to filling out the FOCUS Access Request Form, designed to support users in completing the form accurately. Follow the step-by-step instructions to ensure a smooth submission process.

Follow the steps to successfully complete the access request form.

1. Click the ‘Get Form’ button to access the FOCUS Access Request Form. This will allow you to open the form in an editable format.
2. Begin by filling in the 'SYSTEM ACCESS REQUESTED FOR' section. Provide your first and last name, phone number, and email address.
3. Next, enter your job title and the date of hire. Ensure this information is accurate, as it is vital for your request.
4. In the 'Agency Name and Department/unit' field, specify the name of your agency and the appropriate department or unit you are associated with.
5. Select the functions that apply to your role by placing an ‘X’ in the corresponding boxes. Choose all that apply, including administrative, billing, clerical, clinical, or supervisor.
6. If you are clinical staff, provide your degree and date of graduation in the required fields. If applicable, include your State of Michigan licenses.
7. Licensed staff must enter their NPI number. Physicians should also include their DEA number.
8. Acknowledge that your organization or responsible person must inform MCCMH of any changes in access needs or employment status. This should be understood thoroughly.
9. Fill out the 'REQUESTING SUPERVISOR, Title, and Department' section by providing the supervisor's name, phone number, and fax number.
10. Ensure the supervisor signs the form and includes the date of the request.
11. Finally, verify that all the information is accurate. Sign the form to attest to the completeness and accuracy of the provided details.
12. Submit the completed form via email to FOCUSAccessRequest@mccmh.net or fax it to 586-469-7958. You can also save, download, or print the form for your records.

Complete your access request form online today to ensure timely processing.