SIMON Forms

Training Registration Request Online Form
DBH and Contract employees requesting authorizations to access the InSyst (SIMON) database are required to complete the online form and attend InSyst (SIMON) training.

Charge Data Correction Invoice Form
The purpose of this form is to submit the processing of service deletions and corrections in the San Bernardino Information Management Online Network (SIMON) using a Charge Data Correction Invoice. Fill out the form completely and fax it to the DBH Business Office at (909) 382-3060.

Universal Charge Data Invoice Form
The purpose of the Charge Data Invoice (CDI) is to provide data relevant to services that have been provided so that billing or other cost allocation may be done.

Episode Transfer Procedure
The purpose of this procedure is to transfer an episode from one reporting unit number to another.

InSyst Staff Master Worksheet Online Form
The information obtained on this online form will be used for assigning a “SIMON” number for computerized billing and preparing your Medicare PIN application. This form must be completed by the end of the employee’s second day of employment.

Staff Master Worksheet Update Information Online Form
The information obtained on this form will be used to update current “SIMON” number holder’s information for computerized billing. This form must be completed whenever there is any changes such as renewed license date, change of name, etc.