Philips Lifeline Care Plan Agreement Page 1 of 2Care Plan Agreement • August 12th, 2013 • Massachusetts
This is a PARTIAL InstallThis is a FOLLOW-UP Install Program Name Program Phone Number Installation Date Program Code Household Phone #( ) Model Type Communicator # Accessories Subscriber Mobile Phone #( ) Button # Salutation Subscriber Last Name First Name Middle Suffix Preferred Name Last Name Sounds Like Language Need?Spanish Other GenderMale Female Date Of Birth Household Information Emergency Phone Numbers (Do not list 911 or 800 #’s) Residential Street Address/Apt.# CENTRAL DISPATCH ( ) POLICE ( ) City State Zip Code FIRE ( ) Township/ Municipality County AMBULANCE Check if Private ALTERNATE AMBULANCE ( ) ( ) Household Hidden Key Location Directions To Home (Must Be Provided If PO Box Listed) Subscriber Email Address Special Instructions/Addl. Svcs. PHB/AAHB xmit code: PHB/AAHB exipiry: State FundedLifeline Smoke Detector Healthcare Directives Drug Allergies Medical Conditions and/or Diseases Household Warning R e s p ond e r O ne R e s p ond e r Tw o R es
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Please complete this Care Plan Agreement with information that you would like Lifeline Trained Care Specialists to have ready in case of an emergency. Please return this Care Plan Agreement to Lifeline using the envelope included with your equipment box.
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Care Plan Agreement – Terms and ConditionsCare Plan Agreement • August 12th, 2013 • Massachusetts
Welcome to the Philips Lifeline medical alert service! Below are the legal terms of the Agreement between you and Lifeline. (“Lifeline” means Lifeline Systems Company and its affiliated companies, the Program and Referral Source named on your Care Plan Agreement and each of their affiliated entities.)
