Language
English (US)
Mercarik Referral Form
Is this referral a SAFETY EMERGENCY?
Yes
No
Individual Information
Enter information for the person you are making the referral for. Please skip the question if it does not apply to the person you are making the referral for.
First and Last Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Landline
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
User Email Address
example@example.com
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
Does this person need an Interpreter?
Please Select
Yes
No
List type(s) of interpreter(s) needed
ex: Spanish, Somali, etc
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Referral
*
The more information we have, the better we can match the person with the best first step.
Individual Billing Information
Which waiver or FMS does funding come from?
Insurance ID/PMI
Funding type(s)
*
Traditional Waiver
CDCS
Private Pay
FMS Organization Name
Beginning date of service or plan year
-
Month
-
Day
Year
Date
FMS Contact Name
FMS Email Address
FMS Phone Number
Case Manager Information
Case Manager Name
Case Manager Phone
Please enter a valid phone number.
Case Manager Email
example@example.com
Scheduling
Who should we reach out to coordinate scheduling an appointment with the individual, if needed?
First and Last Name
Best person to schedule assessment/installation with?
Relationship to Individual
Cell Phone Number
Please enter a valid phone number.
Landline Number
Please enter a valid phone number.
Email Address
example@example.com
Best way to reach them
Phone Call - Cell
Phone Call - Landline
Text
Email
Submit
Should be Empty: