Electronic Form Requests (E-Forms):
The following E-Forms on this page are currently available to be completed in lieu of a standard PDF form. As more E-Forms are completed they will be added to the menu for you to access. The E-Forms allow you to complete your request online and immediately submit the completed form to the ACBH IS Support Help Desk (ACHSupport@acgov.org) for processing. A PDF copy of the form will also be emailed to you for your records. Note: To process multiple requests of the same E-Form, simply press the browser refresh icon or the F5 key to reload the E-Form after submitting the form.
Select from one of the following E-Forms to complete your online request. For Help on completing an E-Form, click on the Help link.
SmartCare
ALL staff must have a SmartCare Staff ID number
Submit this eForm in order to get staff a SmartCare Staff ID number.
For staff who need to log on to SmartCare ONLY – not all staff need to log on to SmartCare
Prior to requesting access to the SmartCare system, you must first complete a SmartCare Staff ID Number Request form (above).
Once you receive the SmartCare Staff ID Number, then request login access to SmartCare by completing the SmartCare Staff Authorization form (Step 2).
Submit the request below after the staff has a SmartCare Staff ID number. A completed Confidentiality, Security and Usage Agreement (CSU) and completed Electronic Signature Agreement (ESA) must be submitted before the SmartCare Staff Authorization Request can be fulfilled
In order to complete this form, you must have already received your SmartCare Staff ID Number (see Step 1 above). Once you receive your Staff ID Number, you can then request login access to SmartCare by completing the SmartCare Staff Authorization form.
Use this online e-form for requesting SmartCare (SC) and Clinicians Gateway (CG) Service Notes to be Deleted by the ACBH IS Support Group. For non-CG users who enter services directly into SC and the services are in a "show" status, they can error the service's via the SC Service Entry Screen and should not complete this e-form
Service Requests
- Confidentiality, Security and Usage Agreement (CSU) / Electronic Signature Agreement (ESA)
Required for any person accessing Alameda County Behavioral Health (ACBH) systems (Network, Clinicians Gateway and/or INSYST.
- Confidentiality Statement
Use this online eform to submit an annual Confidentiality Statement. This confidentiality submission is for all substance use contracted providers and all BHCS staff.
- DATAR Web Access Authorization Request
Use this online e-form to setup, update, and remove a username and access to the DATAR (Drug and Alcohol Treatment Access Report) website. An email will be sent to the Help Desk along with a copy of your request. - Report/Data Request E-Form
Use this online e-form to create & modify reports, run existing reports or to request a one-time data pull. An email will be sent to the Help Desk along with a copy of your request - Service Request E-Form
Use this online e-form to make a request for network access.
INSYST
- Authorization (SUD) Request E-Form
Use this online e-form to setup, update or disable an INSYST username and their access to the INSYST database. - Authorization (MHS) Request E-Form
Use this online e-form to setup, update or disable an INSYST username and their access to the INSYST database. - Client Merge Request E-Form
Use this online e-form to merge duplicate INSYST client records. - Staff Number (SUD) Request E-Form
Use this online e-form to request a new staff number, update an existing staff number or expire an existing staff number. - Staff Number (MHS) Request E-Form
Use this online e-form to request a new staff number, update an existing staff number or expire an existing staff number.
CANS/ANSA OA-SMR
- CANS/ANSA Readiness Attestation
The OA-SMR CANS/ANSA Readiness Attestation form is used to certify that your organization has completed the readiness tasks and is prepared to use the OA-SMR application for CANS/ANSA data entry and monitoring.
Clinician's Gateway
- CG Note Delete Request E-Form
Use this online e-form to request a CG Note to be deleted. - CG Staff Authorization Request E-Form
Use this online e-form to Create, Update or Disable a CG staff account.Staff MUST have a SmartCare Staff ID number before submitting the CG Staff Authorization Request. A completed Confidentiality, Security and Usage Agreement (CSU) and completed Electronic Signature Agreement (ESA) must be submitted before the CG Staff Authorization Request can be fulfilled
- CG Staff List Request E-Form
Use this online e-form to add individuals to the RU staff drop-down lists in the CG data collections forms. - CG Treatment Plan Request E-Form
Use this online e-form to request changes to the CG treatment plan. - Electronic Signature Agreement (ESA)/Confidentiality, Security and Usage Agreement (CSU)
Required for any person accessing Alameda County Behavioral Health (ACBH) systems (Network and Clinicians Gateway).
Timely Access Data Tool
This data is for New/New Returning Clients
- Timely Access Data Tool (TADT) Reporting Form
Use this online form to enter your Timely Access Data.
Final Rule Forms
- Provider Directory
Use this online form to provide Service & Cultural information for your organization. This information will be posted on the Alameda County website to provide users with your service information. - State Provider Directory Interim Information Form
Use this online form to update/add the missing information for your organization or private practice that is required by CMS for the State Provider Directory.
Miscellaneous
- Language Interpretation Translation (LIT) Form
Use this online form for requesting language translation services. This form is for Alameda County Behavioral Health Care & their Providers Only. - Provider Monthly Attestation
Use this online e-form to attest to your Monthly Attestation for Staff Changes or NACT/Final Rule Changes. Refer to the User Guide for information on using and completing the Provider Monthly Attestation Form. - Unusual Occurrence Notification
Use this online e-form for Providers to report of an unusual occurrence due to a death or incident in the clinics. - Yellowfin Data Access
Use this online e-form to request access to the Yellowfin data analytics information. An email will be sent to the Data Management & Reporting team with a copy of your request.
If you have any questions regarding the E-Forms, please contact the ACBH IS Support help desk at ACHSupport@acgov.org or 510.817.0076.