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Rocky Mountain Human Services Referral Form

VRI offers a full suite of innovative solutions and connected devices that are reliable and simple to use.

Rocky Mountain Human Services - Referral Form

Case Manager

Name(Required)

Client Information

Name(Required)
Date of Birth(Required)
Address


Type NA if not applicable
Can client be contacted directly?
CTS (Community Transition Services)

Client's Contacts

Contact Name

Type of Equipment Needed

Personal Emergency Response Systems (PERS)

Locked Medication Management Devices
Who will handle the medication for this client?

Do you want an installer to set up the member's device(s)?(Required)

Additional Notes

Is there a delayed installation date?
Max. file size: 50 MB.
To upload a PAR, click the "Choose File" button and select the PAR to be uploaded. The file will be uploaded and saved with your referral submission.