Clone of Mercarik: PERS Referral

  • PERS Programming Referral

    Skip any questions that don't apply to you.
  • Who is Submitting this Referral?

  • 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.
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Which of the following most accurately describes the individual? Choose as many as you like
  • Interpreter Needed*
  • Interpreter Type(s) Needed?
  • 0/30000

  • Individual Billing Information

    Which waiver or FMS does funding come from?
  • Funding Type(s)*
  • Funding source for recurring fees*
  • Format: (000) 000-0000.

  • 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 and Billing Information

  • Format: (000) 000-0000.

  • 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.

  • User Account Information

    What information would you like the call center to have on file?
  • Fall Detection?*

  • User Alert Request

    User would like to receive the listed alerts in the following way(s):
  • Low Battery Alert
  • Power Off Alert
  • Dispatch Alert
  • False Alarm
  • Testing
  • Testing

  • 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.
  • Emergency Contacts Needed?
    • Add Emergency Contact 

    • Emergency Contact 1

      Who would like to be called/notifed?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Error!

      An Emergency Contact must have either Landline or Cellphone completed. 

    • Emergency Contact 1 Alert Request

      Emergency Contact would like to receive the listed alerts in the following way(s):
    • Low Battery Alert
    • Power Off Alert
    • Dispatch Alert
    • Add a 2nd Emergency Contact 

    • Emergency Contact 2

      Who would like to be notified/alerted?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Error!

      An Emergency Contact must have either Landline or Cellphone completed. 

    • Emergency Contact 2 Alert Request

      Emergency Contact would like to receive the listed alerts in the following way(s):
    • Low Battery Alert
    • Power Off Alert
    • Dispatch Alert
    • Add a 3rd Emergency Contact 

    • Emergency Contact 3

      Who would like to be notified/alerted?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Error!

      An Emergency Contact must have either Landline or Cellphone completed. 

    • Emergency Contact 3 Alert Request

      Emergency Contact would like to receive the listed alerts in the following way(s):
    • Low Battery Alert
    • Power Off Alert
    • Dispatch Alert
    • Add a 4th Emergency Contact 

    • Emergency Contact 4

      Who would like to be notified/alerted?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Error!

      An Emergency Contact must have either Landline or Cellphone completed. 

    • Emergency Contact 4 Alert Request

      Emergency Contact would like to receive the listed alerts in the following way(s):
    • Low Battery Alert
    • Power Off Alert
    • Dispatch Alert
    • Should be Empty: