PROVIDER STAFFING INSTRUCTIONS
EXCELL SPREADSHEET/PROVIDER PROFILE
Quarterly Reporting
Column 1 Submit Date. Date data compiled for Board submission. This date will be the same for all staff for the respective reporting periods.
Column 2 UPI#. MACSIS Universal Provider ID. If none, use Board assigned agency ID.
Column 3 Staff # refers to the internal Agency staff number which is used to track MH/AOD services provided by that staff.
Column 4 Current Salary refers to the staff’s current gross yearly salary or salary range. For contract staff, enter the maximum reimbursable amount of the contract, or if no maximum reimbursable amount, the estimated amount the contract staff will draw down.
Column 5 Last Name
Column 6 First Name
Column 7 MI - Middle Initial
Column 8 Position Title refers to the internal Agency definition for the staff person. (Note: Each person responsible for direct services delivery or for supervision must be listed.)
Column 9 Highest Professional Degree refers to the highest educational degree received from an accredited college in a social service field. If none, indicate by writing none.
Column 10 Date Prof. Degree Received - Self-explanatory.
Column 11 ODMH/ODADAS Credentialing Definition refers to the ODMH Administrative Rule 5122-24-01, “Provider Definitions” or Ohio Credentialing Board definitions. List in this column the “Definition” of the staff licensure/credentials for MH/ADA service provision and/or supervision.
Column 12 Licensure # refers to the State Licensure/Certification/Registration number. If none, indicate by writing none. (If more than one licensure, use additional lines as needed, also include Physician’s Controlled Substance Registration)
Column 13 Licensure # Expiration Date - Self-explanatory.
Column 14 Date Hired refers to date staff hired/contracted with to provide services/supervision.
Column 15 Date Left refers to date staff left employment.
Column 16 “# of Years Providing MH/ADA Services” refers to total number of years and should include years in MH/ADA service provision before receipt of “Highest Professional Degree”, if applicable.
Column 17 Supervisor # refers to internal Agency staff number assigned as primary supervisor for the staff person.
Column 18
Column 19 Direct Service
This report is due at the beginning of the FY and quarterly thereafter. Subsequent quarterly reports are to modify/update staffing using the original submission.
Go to: www.mhrbeo.com, Forms to download the spreadsheet to complete this requirement.