Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the organization name at the top of the form. Ensure that the name is accurate as it appears on your official documents.
3. Enter your Tax Identification Number (TIN#) in the designated field. This is necessary for identification and tax purposes.
4. Provide the service address of your organization. Make sure to include the complete address to facilitate communication.
5. In the subsequent sections, you will need to list staff members. For each individual, specify their name, professional licensure level (e.g., Psychiatrist, Social Worker), and their license number.
6. Indicate the age groups served by each staff member by marking the appropriate boxes (0-5, 6-12, 13-17, 18-64, 65+). This helps in categorizing the services provided.
7. Fill out the Social Security Number (SSN#) and Date of Birth for each staff member. Ensure that these details are accurate to avoid any discrepancies.
8. Select the gender of each staff member by marking the ‘M’ or ‘F’ option as appropriate.
9. Complete the Medicare UPIN, NPI, and Medicaid numbers for each individual, if applicable. These numbers are important for billing and insurance purposes.
10. Finally, the form should be completed by an authorized individual. Sign and provide their title and date in the designated area at the bottom of the form.
11. After filling out all required fields, review the form for any errors or omissions. Once satisfied, you can save changes, download, print, or share the completed form as needed.

Act now to complete your Organization Behavioral Health Staff Roster online and ensure your organization meets compliance requirements.