Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth

Personal Emergency Response System (PERS)General Prescription Form

Effective date of prescription: 

Section I (Sections I, II, III, and IV must be completed by the PERS provider.)

Member’s name
MassHealth ID number
Address
Telephone number
Date of birth
Gender M F
Height
Weight
ICD-9 code
Diagnosis

Section II

Prescribing provider’s name
Telephone number
Address
NPI
Fax number

Section III

Supplier’s name
Telephone number
Address
NPI
Fax number

Section IV

HCPCS Code
HCPCS Code

Section V (Sections V and VI must be completed by the member’s prescribing 
physician, nurse practitioner, or prescribing physician’s or nurse 
practitioner’s staff.)

Length of need:

Medical justification for requested item(s)

All questions must be answered “yes” to qualify for a PERS.

1. Does the member have a medical condition that causes significant functional 
limitations or incapacitation that will prevent the member from using other 
methods of summoning assistance in an emergency?  .  .  .  .  .  .  .  .  .  .  
.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  
.  .  .  .  .  .  .  .  .  .  .  yes   no

2. Does the member have a functioning land-line phone that can accommodate a 
PERS?  .  .  .  .  .  .  .  .  yes   no

3. Does the member live alone or is routinely alone for extended periods of time 
such that the member’s safety would be compromised without the availability of a 
PERS unit in the home?.  .  .  .  yes   no

4. Is the member able to independently use the PERS to summon help?  .  .  .  .  
.  .  .  .  .  .  .  .  .  .  .  .  .  .  yes   no

5. Does the member understand when and how to appropriately use the PERS?  .  .  
.  .  .  .  .  .  .  .  .  .  .  yes   no

6. Is the member at risk of moving to a more-restrictive supervised setting, OR 
is the member at risk for falls or other medical complications that may result 
in an emergency situation?  .  .  .  .  .  .  .  yes   no

Section VI

Prescribing Provider’s Attestation and Signature/Date

I certify that I am the prescribing provider identified in Section II of this 
form. I certify that the medical necessity information (per 130 CMR 450.204) on 
this form is true, accurate, and complete, to the best of my knowledge, and I 
understand that I may be subject to civil penalties or criminal prosecution for 
any falsification, omission, or concealment of any material fact contained 
herein.

Prescribing provider’s signature/credentials  (Signature and date stamps are not 
acceptable.)  Date

This completed form must be maintained in the member’s record.

PERS-GPF (01/09)