Change Form1Demographics2HR Information3IT Information4Credible InformationEmployee Information:Type of ChangeNew HirePromotionPayroll ChangeRe-HireTransferIT / Credible Change OnlyEmployee Name First Last Effective Date MM slash DD slash YYYY LicenseDegreeCell PhonePersonal Email DepartmentAdminAOTCBSCBS-QuestCDSClinicalConnectionsCSSFacilityFinancialHRITMedicalOperationsRSVPJob TitleSelect Department FirstAdmin Job TitleChief Financial OfficerChief Operations OfficerClinical Data Reporting and Design AdministratorCoordinator of Prevention and OutreachDeputy DirectorDirector of Clinical ServicesDirector of Coffeyville OperationsDirector of Community Based ServicesDirector of Community Support ServicesDirector of Cowley Branch OfficeDirector of Human ResourcesDirector of Information TechnologyDirector of Operational Support and TrainingDirector of Program DevelopmentDirector of Quality Improvement and Risk ManagementExecutive AssistantExecutive DirectorAOT Job TitleCrisis and Community Outreach Service CoordinatorCBS Job TitleAttendant CareAttendant Care-Group LeaderKids KonnectionCase Manager (CPST)Case Manager (Project Before)Case Manager (TCM/Care Coordinator)Home Visiting Central Intake SpecialistHome Visiting Intake Program CoordinatorParent Education SpecialistParent Support SpecialistProgram CoordinatorSpecial Programming CoordinatorSpecial Programming SupervisorSupport Staff - Waiver SpecialistTherapist - Early Childhood MH ConsultantCBS-Quest Job TitleAttendant Care-DispatchAttendant Care-Group LeaderAttendant Care-Group Leader - Adventure BasedProgram Site SupervisorPsychosocial AideSite SupervisorCDS Job TitleAssistant Director of Clinical ServicesCrisis Support SpecialistCrisis Support Specialist + ReceptionistCase Manager (Assertive Community Treatment)Case Manager - Back-up On CallCase Manager (Mobile Crisis) - On CallCase Manager - CDS On CallCase Manager - On Call + Crisis Support Specialist Supervisor + Hospital LiaisonCase Manager (Co-Responder)Case Manager (Dispatcher)Case Manager (Transistions)CDS Therapist - CDS On CallCDS Therapist - On Call - TelevideoHospital LiaisonProgram Coordinator - CDS On Call BackupProject Administrative AssistantRegistered NurseTherapist (ACT Team Lead)Therapist (Daytime Position On-Call Backup)Therapist - InternTherapist - On CallTherapist - PRNClinical Job TitleCase ManagerClinical Services Operational SupportCHC Integrated Care TherapistFamily Caregiver Support SpecialistInternOperational SupportPeer Recovery MentorProgram CoordinatorSUD CounselorSUD Program CoordinatorTherapistTherapist - BilingualTherapist - MedicareTherapist / Co-Occuring ProviderTherapist / Co-Occuring Provider - SupervisorTherapist / MHIT Program SupervisorConnections Job TitleProgram CoordinatorDirector of Transportation and Special ProjectsDispatcherDriver-DOTDriverDriver-DOT LeadSupport StaffCSS Job TitleAttendant CareAttendant Care Shared LivingCase Manager (Clubhouse Supervisor)Case Manager (Clubhouse)Case Manager (CPST)Case Manager (EES)Case Manager (IDDT)Case Manager (SOAR)Case Manager (Strengths Based)Coordinator for First Episode NavigationCertified Peer Support (MH)Program CoordinatorPsychosocial AideFacility Job TitleCourierDirector of MaintenanceMaintenance SupportMaintenance/CustodianFinancial Job TitleGrant Projects ManagerStaff AccountantHR Job TitleAssistant HR Director/ Operations CoordinatorOperations SpecialistPayroll and Benefits SpecialistRecruiting SpecialistIT Job TitleComputer Technician IComputer Technician IIDatabase administratorInformation Technology AdministratorSenior Applications AdministratorSenior Systems AdministratorSenior Systems ManagerSystems AdministratorMedical Job TitleCertified Medical AssistantCertified Medical Assistant (Supervisor)Certified Nursing AssistantInjection NurseIntegrated Health Outcomes CoordinatorIntegrated Health SpecialistIntegrated Health Specialist/CDSLicensed Practical NurseMedical DirectorMid-Level PractionerProgram CoordinatorRegistered NurseStaff PsychiatristSupport Staff - Medical ServicesOperations Job TitleBilling and Finance SpecialistBilling LeadBilling Support StaffBusiness Office ManagerInterpreterMarketing and Recruiting SpecialistOperational Support SupervisorPayables AccountantPatient NavigatorPatient Navigator - Community Health WorkerPatient Navigator - (SMVF)Peer Services SupervisorQuality Review SpecialistSupport StaffSupport Staff - BilingualSupport Staff - Front Desk - RegistrationSupport Staff - Medical RecordsSupport Staff - Project SpecialistSupport Staff - TranscriptionUtilization Review Support SpecialistRSVP Job titleProgram CoordinatorSupport StaffBusiness Cards: Yes No(see approved position title)Location(s) employee will be working from:01-IND-MAIN02-CVILLE05-NEODESHA06-FREDONIA08-SEDAN09-HOWARD11-LONGTON14-COWLEY16-LAUREL-STREET-OFFICE20-IND-NORTHSupervisor First Last Supervisor PhoneHR Information:Work ScheduleReplacement For:Status Full Time P/T KPERS (>1,000 hrs) P/T (<1,000 hrs) P/T + Insurance Payroll Services Express Clerical Testing Standby TemporaryWage Information: Exempt (Salary) Non-Exempt (Hourly)Shift Differential Full Half N/AFour County Salary:per: Year HourSpecial Conditions (if any):Will Be Reimbursed for Cell Use? Yes NoWage Allocation: must equal 100%% Add RemoveDepartment # Add RemoveProgram # Add RemoveSupervision and KeysStaff names if Supervision change:Company Mileage: Yes NoPhysical Keys Needed? Yes NoPhysical Keys FC Main Interior Doors Connections DoorsKey to Office of:Other Keys:IT InformationPhone:Cell Phone No Cell Needed Need Company Cell Will Use Personal CellPersonal Cell #Desk Phone Needed? Yes NoDesk Phone #:Key Card Access Needed? Yes NoSecurity Access Level Employee Level Employee Level + Admin (Main West Wing) Employee Level + Cville Storage/Records Employee Level + Cville Medical RoomEmail:Email Needed? Yes NoEmployees will be automatically included in the All Staff email group unless marked here: Exclude from All Staff EmailWhat email groups should this employee be added to?Email Groups Alcohol Drug Staff Billing Building Coffeyville Building Cowley Building Indy Main Building Indy North Connections Coordinators Executive Team Executive Support Team Healthcare Services Health Home Staff Hospital Discharge Group HR Department Integrated Health Specialists Medical Records Medical Staff Nurses Wellness GroupEmail Groups Clinical Services Clinical Services Coordinators Outpatient All Outpatient Coffeyville Outpatient Independence Outpatient Cowley CBS CBS Attendant Care CBS CM Staff CBS CM Staff - Coffeyville CBS CM Staff - Cowley CBS CM Staff - Independence CBS Coordinators CBS Hope CBS QMHP's CBS SEK Academy CBS Support Staff CDS CDS - Cowley CDS - CBS CDS - CSS CDS - OPEmail Groups CSS CSS Attendant Care CSS CM Extended Hours CSS Case Managers CSS Clinical Services CSS CLUB CSS Coffeyville Team CSS Coordinators CSS DBT Consultation Team CSS EES Program CSS Independence Team CSS Outbackers Team CSS Shared Living CSS TCM Case Managers CSS Cowley Team Support Staff Front Desk - Coffeyville Front Desk - Cowley Front Desk - Main Front Desk - North West Wing AdministrationComputer Needs:Credible Access Needed? Yes NoPlease detail level needed:Chromebook Needed? Yes NoPlease detail level needed:KMAP Access Needed? Yes NoPlease detail level needed:Other Software Needed? Yes NoPlease detail level needed:Credible Information:Primary Program:AdministrativeCCBHCCommunity Based Services ChildrenCommunity Support Services AdultConnectionsCrisis ServicesEarly Childhood Block GrantHealth Care ServicesMedicalOne CareOutpatient ClinicalSUD OutpatientAdditional Programs Yes NoSelect Multiple Programs if Needed: Administrative CCBHC Community Based Services Children Community Support Services Adult Connections Crisis Services Early Childhood Block Grant Health Care Services Medical One Care Outpatient Clinical SUD OutpatientPrimary Team:ACT EastACT WestBillingCBS CowleyCBS CvilleCBS IndyCBS Kids KonnectionCBS QuestCBS SEKCrisis ACCrisis CMCrisis QMHPCSS ACCSS ClubCSS CowleyCSS CvilleCSS EESCSS Indy/OutbackCSS SLData IntegrityECBGIHSMED CowleyMED CvilleMED IndyOP CowleyOP CvilleOP IndySUD CowleySUD CvilleSUD IndyAdditional Teams Yes NoSelect Multiple Teams if Needed: ACT East ACT West Billing CBS Cowley CBS Cville CBS Indy CBS Kids Konnection CBS Quest CBS SEK Crisis AC Crisis CM Crisis QMHP CSS AC CSS Club CSS Cowley CSS Cville CSS EES CSS Indy/Outback CSS SL Data Integrity ECBG IHS MED Cowely MED Cville MED Indy OP Cowley OP Cville OP Indy SUD Cowley SUD Cville SUD IndyProfile Code:Tech (Attendant Care/Psychosocial Aide)BillingBilling SupportClinicianCMFront DeskHRIntakeMedicalMedical SPMedRecordsNonSPI PrescReadOnlySuperUserSupervisorTechBilling Groups:A/D SUDACT CMACT INDCBS Case ManagementCBS CM TherapyCBS Day TreatmentCBS DT TherapyCBS QuestCBS Quest TherapyCommercialConnectionsCSS Attendant CareCSS Case ManagementCSS ClubhouseCSS CM TherapyCSS EESCSS Shared LivingCSS SoarFCMHCSED WaiverTelemedAdditional Billing Groups Yes NoSelect Multiple Billing Groups if Needed: A/D SUD ACT CM ACT IND CBS Case Management CBS CM Therapy CBS Day Treatment CBS DT Therapy CBS Quest CBS Quest Therapy Commercial Connections CSS Attendant Care CSS Cases Management CSS Clubhouse CSS CM Therapy CSS EES CSS Shared Living CSS Soar FCMHC SED Waiver TelemedDisciplineBachelors LevelBelow BachelorsDedicated CrisisMid-Level (PA/APRN)PsychiatristQMHPSubstance Abuse CounselorSupporting Staff
