FMS PAY - Uber Health Program Enrollment
Enter accurate client and contact details, confirm monthly allotment, and submit your enrollment for review.
Client Information
Client Name
*
First Name
Last Name
Client UCI Number
*
Client Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Birth must match Uber records as well
Regional Center
*
Mobile Phone Number Used for Uber Account
*
Please enter a valid phone number tied to your Uber account.
Format: (000) 000-0000.
Email Address
*
example@example.com
Who is completing this form
Who is completing this form?
*
I am the client
I am the client's parent or legal guardian
I am the client's authorized representative
I am the client's Independent Facilitator
I am helping the client in another capacity
Name of person completing this form
Leave blank if you are the client. If you are an Independent Facilitator or someone else assisting, enter your name here.
Relationship to the client
Monthly Allotment
Monthly Uber allowance request:
*
e.g. $500/month - Resets on the 1st of each month, can be adjusted by FMS Pay staff throughout the year as needed.
Acknowledgements
I understand that rides through this program must be for purposes included in the client's approved spending plan.
*
I understand
I understand that only rides taken within California can be funded. The Self-Determination Program is a California program, and SDP funds must be utilized in-state per W&I Code section 4519. Rides taken outside California will not be covered and may become my financial responsibility.
*
I understand
I understand that the mobile number provided above will be used to link and coordinate rides, and I will notify FMS Pay if it changes.
*
I understand
I confirm that the information provided on this form is accurate and complete.
*
I confirm
This form must be signed by the client, or by their parent, legal guardian, or authorized representative. If you are an Independent Facilitator or another person assisting, please have the client or their representative review the acknowledgements above and sign below.
Client Signature
Printed name of client or authorized representative
*
First Name
Last Name
Signature of client or authorized representative
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Enrollment
Submit Enrollment
Should be Empty: