Disable User(s) in Provider Direct
 
Please fill out the form below if you need to REMOVE an employee from having access to the PBH Provider Direct system.
 
     
Agency Name:
  
     
Agency ID#:
   please note this MUST be a number
     
Supervisor's Name:
 
     
Supervisor's Phone:
  
     
Supervisor's Email:
 
     
   
Employee Name:
  
     
Disable Employee?:
  Yes
     
Reason:
  
     
 
 

Should you have any additional questions, please click here. Thank you.

PBH IS Department
Provider Direct