Mercarik: Referral Form

Mercarik Referral Form
Integration User ID
None Account ID
Record Type ID
Is this referral a SAFETY EMERGENCY? (prioritized scheduling 5-8 weeks out - additional $200)
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.
Name

Individual's First NameIndividual's Last Name
Date of Birth

MonthDayYear
Please enter the individual's birthday.
Individual's Landline
Please enter the individual's phone number, if applicable. (Please do not enter contact information for the CM or a family member here)Format: (000) 000-0000.
Individual's Mobile Number
Please enter the individual's cell number, if applicable. (Please do not enter contact information for the CM or a family member here)Format: (000) 000-0000.
Individual's Email Address
Please enter the individual's email, if applicable. (Please do not enter contact information for the CM or a family member here)
Which of the following most accurately describes the individual? Choose as many as you like.
Let Me Type - response
Interpreter Needed?
Interpreter Type(s) Needed?
Interpreter(s) Needed (Other)
Please list all additional interpreter(s) needed
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Are There any Safety Concerns our Staff Should Know About?
Safety Concern Follow Up
Please provide as much detail as our staff will need to know when conducting the assessment
Are There Any Environmental Factors our Staff Should Know About?
Environmental Factors Follow Up
Please provide as much detail as our staff will need to know when entering the home.
Reason for Referral (can choose more than 1)
Is this referral for an Urgent Order?
Reason for Referral

The more information we have, the better we can match the person with the best first step.0/30000
Individual Billing Information

Which waiver or FMS does funding come from?
Insurance ID/PMI
Funding type(s)
FMS Organization Name
FMS Contact Name

First NameLast Name
FMS Contact Name (Outdated)
FMS Email Address
example@example.com
Error! You will not be able to submit until this error is corrected.

The Email for FMS Contact should not be the same as the Individual.

Please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
FMS Email Address (Outdated)
example@example.com
FMS Phone Number
Format: (000) 000-0000.
Case Manager Information
Case Manager Name

First NameLast Name
Organization / County
Case Manager Name (Outdated)
Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email
example@example.com
Error! You will not be able to submit until this error is corrected.

The Email for Case Manager should not be the same as the Individual.

Please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
Case Manager Email (Outdated)
example@example.com
Scheduling

Who should we reach out to coordinate scheduling an appointment with the individual, if needed?
Scheduler is Individual?
Scheduling Contact Name

First NameLast Name
First and Last Name
Best person to schedule assessment/installation with?
Relationship to Individual
Relationship to Individual (Outdated)
Scheduler Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Scheduler Landline Number
Please enter a valid phone number.Format: (000) 000-0000.
Scheduler Email Address
example@example.com
Will this person be present at the appointment?

Other
Error! You will not be able to submit until this error is corrected.

The Email for Scheduler should not be the same as the Individual.

If the Scheduler is the Individual, please select 'Yes' for 'Scheduler is Individual' question above. Otherwise, please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
Email Address (Outdated)
example@example.com
Best Way to Reach Scheduler?
Best Way to Reach Individual?
Should be Empty:

Mercarik Referral Form

Individual Information

Individual Billing Information

Case Manager Information

Scheduling