Tips on Filling Out the Lifeline Care Plan Agreement Form

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Horatio Stevenson
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1 Tips on Filling Out the Lifeline Care Plan Agreement Form The following information is required for the processing of your Lifeline Application: Household Phone # - Include area code and phone number. Salutation - Mr., Mrs., Ms, etc. Subscriber Last Name First Name Middle Suffix - Sr., Jr., II. III., etc. Preferred Name - Nicknames or the name you prefer; Mrs. Smith vs. Betty. Last Name Sounds Like - In cases of unusual names, please give a phonetic spelling of your name. - If you have a special language need please list it here. Gender Date of Birth Household Address Information - Provide Street address, building or apartment number, city, county and zip code. Emergency Phone Numbers (Do Not Use 911) - Lisa will fill these numbers in. Directions to Home - Give directions to your house from Cookeville. Special Instructions Household Warnings - Mean dog, etc. Drug Allergies Medical Conditions and/or Diseases It s the Way WeCARE Personal Contact Information - Provide the indicated information for each responder. The responder s are the first people Lifeline monitors will contact to come to the aid of the subscriber unless requested specifically to call emergency personnel. They may be relatives, friends, neighbors or on-site emergency personnel, but they should be close enough to be able to come to the aid of the subscriber quickly. Ideally, each should have keys to the subscriber s residence. Please list responders in the order that they should be contacted. Also, make sure that each agrees to be a responder. Notify Only - List any relatives or interested parties who are unable to be listed as responders yet wish to be notified in case of an emergency. Primary Physician - Subscriber s physician(s) will be notified once installation is complete. Preferred Hospital Name - Should it be necessary, Lifeline monitors will attempt to advise emergency personnel of the subscriber s hospital preference. However, in an emergency situation, emergency personnel will transport the subscriber to the hospital most appropriate for the particular situation. If you have any questions please contact Lisa Eldridge, Volunteer Services/Lifeline Program Coordinator at

2 Lifeline Systems, Inc. 111 Lawrence Street Framingham, MA Lifeline Care Plan Agreement Page 1 of 2 q This is a PARTIAL Install (Must complete all fields outlined in bold) q This is a FOLLOW-UP Install; Number of pages included: 1 q or 2 q Program Name Program Phone Number CRMC Auxiliary Program Code Model Type Unit # Household Phone # Installation Date TN031 Salutation Subscriber Last Name First Name Middle Suffix Preferred Name Last Name Sounds Like Gender Date of Birth Household Information Residential / Apt. # q Male q Female Emergency Phone Numbers (Do not list 911 or 800 # s) CENTRAL DISPATCH City State Zip Code POLICE FIRE Township Municipality County AMBULANCE q Check if Private ALTERNATE AMBULANCE Household Hidden Key Location Directions To Home Drug Allergies Medical Conditions and/or Disease Household Warning Responder One Responder Two Responder Three

3 Lifeline Systems, Inc. 111 Lawrence Street Framingham, MA Lifeline Care Plan Agreement Page 2 of 2 Program Code TN031 Subscriber Last Name First Name Household Phone # Notify Program Name Notify CRMC Auxiliary Primary Physician Third Party Notify Fax Number Phone Fax Number Preferred Hospital Referral Source Hospital Name Phone City, State Phone (REQUIRED) Organization/Agency Name Position Title q Multiple Subscriber Household (You must complete a separate Care Plan Agreement for each Subscriber) Name of Additional Subscriber Coupon Code Referral Source Code - Promotion Code Subscriber Notes Payer Information First Name (If applicable organizaiton name) Last Name Home Phone # Work Phone # City State Zip Code Monthly Fee(s) Monitoring Service $ Auto Alert $15.00 extra per month One Time Fee(s) Enrollment Fee $ $ Shipping & Handling $ Payment Frequency q Monthly q Quarterly q Yearly For Program Use Only (Not to be Entered by Data Entry) Signature of Subscriber Date Signature Of Payer (If Different) Date

4 It s the Way WeCARE

5 1 - Choose a Communicator CarePartner Communicator This Communicator works with your existing telephone to provide a direct, two-way connection to Lifeline.

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