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  • Enrollment Request and Inquiry Form



    Please complete this form to get more information or set up an appointment with a PICS representative. We will contact you to start the enrollment process. 

     

    Individual Managing Services

    First Name:        
     

    Last Name:        
     

    Relationship to individual receiving services: 
     

    Home Phone:    
     ) -  - 

    Cell Phone:       
     ) -  - 

    Email (if any):                 
     

    Street Address: 
     

    City:                    
     

    State


    Zip Code:          
     

    County:             

     


    Individual Receiving Services

    First name:        
     

    Last name:        
     

    Same information for individual receiving services? 
     

    If any information differs from the individual managing services please complete below:

    Home Phone:   
     ) -  - 

    Cell Phone:       
     ) -  - 

    Email:                 
     

    Street Address: 
     

    City:                    
     

    Zip Code:           
     

    County:              

     


    Waiver Information 

    The type of waiver type you receive:

             

    The start date of your waiver:

     
    The type of business model you are interested in: 
                                                      

    Are you coming from another Fiscal Support Entity (FSE)? 

             

    If you selected "Yes," please provide the name of your previous FSE: 
     

       


     
     

    How did you heard about PICS?  

     

    Any comment or question: