Clone of Mercarik: PERS Referral

Integration User ID

None Account ID

Record Type ID

Name*

Individual's First NameIndividual's Last Name

Date of Birth*

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)

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)

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*

YesNo

Interpreter Type(s) Needed?

Interpreter(s) Needed (Other)

Please list all additional interpreter(s) needed

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Reason for Referral*

The more information we have, the better we can match the individual with the best PERS/GPS Tracking device.0/30000

Insurance ID/PMI*

Funding Type(s)*

Traditional WaiverCDCSPrivate Pay

Funding source for recurring fees*

Traditional WaiverCDCSPrivate Pay

FMS Organization Name*

FMS Contact Name*

First NameLast Name

FMS Email Address*

example@example.com

FMS Phone Number*

Please enter a valid phone number.

Error! FMS Contact Email Duplicate.

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.

Case Manager Name*

First NameLast Name

Organization / County

Case Manager Email*

example@example.com

Case Manager Phone*

Please enter a valid phone number.

Error! Case Manager Email Duplicate.

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.

Allergies

Medical Conditions

Hidden Key OR Lockbox Code/Location

Special Instructions

Preferred Hospital

Fall Detection?*

YesNo

Low Battery Alert

EmailCell Phone

Power Off Alert

EmailCell Phone

Dispatch Alert

EmailCell Phone

False Alarm

EmailCell Phone

Testing

EmailCell Phone

Testing

Cell PhoneType option 2

PERS Programming Referral

Individual Information

Individual Billing Information

Case Manager and Billing Information

User Account Information

User Alert Request

PERS Emergency Contacts

Emergency Contact 1

Emergency Contact 1 Alert Request

Emergency Contact 2

Emergency Contact 2 Alert Request

Emergency Contact 3

Emergency Contact 3 Alert Request

Emergency Contact 4

Emergency Contact 4 Alert Request