Medicaid

WHO IS COMPLETING THIS ORDER FORM? *

Watch Recipient / Participant

Case Manager/ Care Coordinator

WHO IS THIS WATCH FOR? *

Please Complete Watch Recipient / Participant

First Name

Last Name

Wearer Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Physical Address (no PO Box) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is Shipping Address same as Physical Address? *

Yes

No

Would the user like to access the online user portal? *

User portal displays activity history (steps, heart rate) and watch status.

Yes - please enter participant email

No

EMERGENCY CONTACT INFORMATION (for PERS) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Select to Enter 2nd Emergency Contact

Do you have a Legal Guardian?

Yes - same as Emergency Contact

Yes - different from Emergency Contact - please enter below

No

CARE PROVIDERS AND COVERAGE *

REQUIRED: Case Manager/ Care Coordinator Information:

First Name

Last Name

Phone *

(###)

###

####

Confirmation *

I validate that the authorization form is complete and accurate, reflecting currently published products and pricing. (See Reference Materials if needed)