Avatar Account Request Form
City and County of San Francisco
Department of Public Health
Behavioral Health Information System
1380 Howard St., 3rd Floor
San Francisco, CA 94103
Use this form to request an Avatar Account
Civil Service staff can also request PC login & e-mail
Avatar Training:
Date:
Date of Request:__________________________ 
New (Civil Service, complete additional info on p.2)
Reactivate Avatar Acct**
Update Avatar Permissions*
Update Program
 Deactivate Avatar Acct
Update Name
If Update, include your Staff ID__________ Contractors require Webconnect/DUO.
*If you are updating your credentials, you must also submit a new Credentialing and Verification Form.
Staff Information: **If reactivating Avatar Account, fill in Avatar User Name: ______________________
Last: _________________________________ First: ___________________________________ MI: ___
Job Title: _____________________________________ E-mail: __________________________________
Office Phone: __________________________
Cell Phone: _____________________________
Program Information: Civil Service
Contract Agency
Please select all that applyMental Health
Substance Use Disorder
Adult/Older Adult Child Youth & Family
Outpatient Residential Crisis Prevention Other _____________________
Program Name: ____________________________________________________ RU: _____________
Street Address: ___________________________ City: _____________________
State: ______
Zip Code: ___________ Agency Phone: __________________ Agency Fax: ____________________
2nd Program Name*: __________________________________________________ RU: ____________
*NOTE: Also indicate your second program on the Certification and Verification form.
Street Address: ___________________________ City: _____________________
State: ______
Zip Code: ___________ Agency Phone: __________________ Agency Fax: ____________________
Job Functions/Role
Clerical Intake Clinical Clinical Supervisor Manager/Director
Prescriber Residential Residential Billing Indirect services Lookup/MH140
Using Avatar Scheduling Calendar Using Avatar Portal Other:_______________________
For staff requiring co-signature/approval, list up to 4 licensed supervising staff:
1)
2)
3)
4)
Special Programs: FMP
BHAC FCMH
ERMS (previously AB3632)
BHS 1380 Howard/101 Grove Administration Use ONLY: (Select the appropriate role)
Billing Unit Medical Records Unit
Quality Management IS Applications/IT
CDTA/BOCC System of Care PPN Provider Relations
Compliance
Other:________________
MSO
Fiscal
STAFF AND SUPERVISOR SIGNATURES REQUIRED ON NEXT PAGE
Avatar Account Request KH 05-12-2017
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Avatar Account Request Form
City and County of San Francisco
Department of Public Health
Behavioral Health Information System
1380 Howard St., 3rd Floor
San Francisco, CA 94103
Training Verification and Signature Page
Avatar Account cannot be provided without Proof of Training and Original
Signatures below.
Signatures
Employee Signature: _________________________________________________ Date: ______________
Supervisor Name:_____________________ Phone: _____________ E-mail: _________________________
(print)
Supervisor Signature: _________________________________________________Date: ________________
If training was conducted by your on-site Certified Avatar Trainer, a Post Evaluation is required.
Please complete the following:
Print Trainer Name:
Trainer Phone:
Trainer E-mail:
Avatar Questions may be directed to Avatar HelpDesk at 415-255-3788
Submit completed form(s) and supporting document(s) to:
Behavioral Health Information Systems
1380 Howard Street, 3rd Floor
San Francisco, CA 94103
ATTN: AVATAR Accounts Manager
FAX: 415-252-3008
Civil Service Staff ONLY
Please indicate if you need the following:
Computer Log On (Active Directory). Make account same as, ____________________
Access to Shared Folder (include names): _____________________________________________________
E-mail Account (enter your DSW#):________________
A ticket will be created with the DPH HelpDesk.
Please call DPH HelpDesk at 415-759-3577 to follow up on Active Directory, Shared Folder or E-mail requests.
Avatar Account information (IS STAFF USE ONLY)
System Code:
Login ID:
User Roles assigned:
Created by (Initials):____
Avatar Account Request KH 05-12-2017
Date:______________
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