Language
English (US)
PERS programming information
Skip any questions that don't apply to you.
User Information
User First and Last Name
User Email Address
example@example.com
User Landline
Please enter a valid phone number.
User Cell Phone Number
Please enter a valid phone number.
Which of the following most accurately describes the individual? Choose as many as you like
Male
Female
Non-Binary
Transgender
Intersex
Let Me Type
I Prefer Not to Say
Let Me Type - response
Language
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
/
Month
/
Day
Year
Date
Case Manager and Billing Information
Case Manager Name
First Name
Last Name
Case Manager Email
example@example.com
Case Manager Phone
Please enter a valid phone number.
Funding source for device
Traditional Waiver
CDCS
Private Pay
If CDCS is funding source, please name FME/FMS org (PICS, ACCRA, etc)
CDCS contact name
First Name
Last Name
CDCS contact email
example@example.com
Funding source for recurring fees
Traditional Waiver
CDCS
Private Pay
If CDCS is funding source, please name FME/FMS org (PICS, ACCRA, etc)
CDCS contact name
First Name
Last Name
CDCS contact email
example@example.com
User Account Information
What information would you like the call center to have on file?
Allergies
Medical Conditions
Hidden Key OR Lockbox Code/Location
Special Instructions
Preferred Hospital
Fall Detection?
Yes
No
User Alert Request
User would like to receive the listed alerts in the following way(s):
Low Battery Alert
Email
Cell Phone
Power Off Alert
Email
Cell Phone
Dispatch Alert
Email
Cell Phone
False Alarm
Email
Cell Phone
Testing
Email
Cell Phone
Testing
Cell Phone
Type option 2
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PERS Emergency Contacts
In an emergency the response center will call all contacts who are Responders until one is reached who can respond. Contacts to be notified will be contacted once help is on the way.
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Add Emergency Contact
Emergency Contact 1
Who would like to be called/notifed?
First and Last Name
Landline Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship Type
Is this contact able to respond?
Contact Before Dispatch?
Has Keys?
Emergency Contact 1 Alert Request
Emergency Contact would like to receive the listed alerts in the following way(s):
Low Battery Alert
Email
Cell Phone
Power Off Alert
Email
Cell Phone
Dispatch Alert
Email
Cell Phone
Add a 2nd Emergency Contact
Emergency Contact 2
Who would like to be notified/alerted?
First and Last Name
Landline Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship Type
Is this contact able to respond?
Contact Before Dispatch?
Has Keys?
Emergency Contact 2 Alert Request
Emergency Contact would like to receive the listed alerts in the following way(s):
Low Battery Alert
Email
Cell Phone
Power Off Alert
Email
Cell Phone
Dispatch Alert
Email
Cell Phone
Add a 3rd Emergency Contact
Emergency Contact 3
Who would like to be notified/alerted?
First and Last Name
Landline Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship Type
Is this contact able to respond?
Contact Before Dispatch?
Has Keys?
Emergency Contact 3 Alert Request
Emergency Contact would like to receive the listed alerts in the following way(s):
Low Battery Alert
Email
Cell Phone
Power Off Alert
Email
Cell Phone
Dispatch Alert
Email
Cell Phone
Add a 4th Emergency Contact
Emergency Contact 4
Who would like to be notified/alerted?
First and Last Name
Landline Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship Type
Is this contact able to respond?
Contact Before Dispatch?
Has Keys?
Emergency Contact 4 Alert Request
Emergency Contact would like to receive the listed alerts in the following way(s):
Low Battery Alert
Email
Cell Phone
Power Off Alert
Email
Cell Phone
Dispatch Alert
Email
Cell Phone
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Submitted By:
First Name
Last Name
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