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External Provider - Add/Remove Staff - Sentri
External Provider - Add/Remove Staff - Sentri
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Sentri Add or Remove Staff Form
Subject
A short description to explain the nature of a ticket.
Add Staff or Remove Staff
Add Staff or Remove Staff
Add Staff (New Account)
Remove Staff
Will the staff requested need to login to Sentri?
No
Yes
Provider Agency Name
First/Last Name
Hire Date
(mm/dd/yyyy hh:mm AM/PM)
Termination Date
(mm/dd/yyyy hh:mm AM/PM)
Job Title
Staff's Program / Team Assignment
Staff Phone Number
Staff Email
AIM Staff Type
Administrator (View Only)
Ancillary Services
Clinical Supervisor
Clinician - Primary Case Holder
Clinician - Secondary Case Holder
Finance Worker - Provider Non CI
Finance Worker - SCCMHA
Human Resources
Nurse
Psychiatrist/PA/NP
SCCMHA Administrative Power User
SCCMHA IS
Student/Intern
Rights Officer
Universal Clinician
Supervisor
Is this person replacing someone?
No
Yes
Who is being replaced?
Does this user require the ability to enter claims?
No
Yes
Would you like this user to be signed up for claims training?
No
Yes
Does the staff provide SUD services?
No
Yes
Do you require ASAM Continuum Assessment access?
No
Yes
Credentialing Packet
File attachments associated with the ticket.
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Other Fields
Your name
Your first name
Your last name
Your email address
Your phone number
Verification Code