Instructions for Completing Form

Request Type

• New User ID – no previous access requested
• Change Access – current User ID requires name, level, division or provider change; additional system(s) access; or remove some system(s) access
• Revoke User ID – current User ID no longer needs access to DMH systems

Part 1: User Information

New User ID Request

• Complete last name, first name, middle initial, last four digits of SSN, city, phone, email (must be unique to you and not shared email address), and title.
• Select which division is appropriate for your access.
• Select the Provider name in drop down box.  (Facility Code/FTP will auto-populate based on what is selected in the Provider field.) 
  • If access is needed to additional providers, indicate the additional provider facility codes/FTPs in the Comment field.
• If your Provider isn’t listed, please select “Other”, then type in the Comment field your provider agency name and submit the form so appropriate staff can follow up.

Change Access Request

• Complete last name, first name, middle initial, last four digits of SSN, city, phone, User ID, email and title.
• Select which division is appropriate for your access.
• Select the Provider name in drop down box.  (Facility Code/FTP will auto-populate based on what is selected in the Provider field.) 
• Type in the Change Request field what needs to be changed and/or if dual access is needed.

Revoke User ID Request (to be submitted by LSO)

• Complete last name, first name, middle initial, last four digits of SSN, city, phone, User ID, email and title for user needing access revoked.
• Select which division access was under for user.
• Select the Provider name in drop down box.  (Facility Code/FTP will auto-populate based on what is selected in the Provider field.) 

Part 2: Confidentiality Statement

• Read the confidentiality statement.
• After reading, select the check box to acknowledge that you have read the statement.
• After everything on the form is complete, sign as indicated and select Submit to send the request to your Local Security Coordinator (LSO).
• The Local Security Coordinator (LSO) will review your submitted form and approve to route the form to the appropriate Division.

Part 3:

The below applications are now requested through DARS ONLINE.  On the DMH Portal under the “Security Access Request” section, select the “DMH Application Request System (DARS) – Non-CIMOR Access” link. 

NOTE: you will need to have a user id and password in order to access DARS.  DARS instructions will be under “Security Access Request” section, labeled “DARS instructions for External Users”.

• Mortality Review (DD RESIDENTIAL PROVIDERS ONLY)
• Consumer Referrals (DD RESIDENTIAL OR TCM PROVIDERS ONLY)
• Integrated Quality Management Functions Database (TCM OR SB40’S ONLY)
• CVS (Approved Behavioral Health Providers ONLY)

Select Provider below. If your Provider isn't listed, please select "Other", type in your Provider name in the Comment box below and submit the form so appropriate staff can follow-up.

Selected Provider doesn't have a Local Security Officer. Please submit this form with the required fields so appropriate staff can follow-up.

I, the undersigned, a designated representative of the provider named above, understand that the approval and assignment of the requested ID or change request enables me to access the Department of Mental Health information systems. I understand that federal and state laws, require confidentiality of the Department of Mental Health information and provide penalties for unauthorized access, use, or disclosure of this information. I agree to keep confidential all information made available to me through this access. I also agree not to divulge or share my password with anyone.

I agree to use the information obtained through these systems for purposes directly connected with the administration of a federal/state assisted program which provides assistance in cash or in kind, or services, directly to individuals on the basis of need. I agree to access only the information needed to fulfill my job duties associated with working with the Department of Mental Health. I further agree to comply with the policies and procedures established by the Department of Mental Health further governing the access and use of this information.

Violations or disclosures on my part may result in loss of access to the information systems, civil court action, or cancellation of the provider contract with the Missouri Department of Mental Health.