Lifeline Care Plan Agreement - Hayward Area Memorial Hospital
Contents
1. CJ Multiple Subscriber Household Complete a separate Care Plan Agreement for each Subscriber Organization Agency Name Street Address City State Zip Code Name of Additional Subscriber Coupon Code A B Cc Subscriber Notes Payer Information Payer Email Address Home Phone Work Phone Name First Last or if applicable organization name Street Address Mobile Phone Zip Code Medicaid Number City Monthly Fee s One Time Fee s Payment Frequency Payment Method Monitoring Service Enrollment Fee LI Monthly O Invoice O Quarterly L Credit Card Shipping amp Handling O Yearly L Debit Card Signatures of Subscriber and if different Payer SUBSCRIBER By signing below you confirm that 1 PAYER if not Subscriber By signing below the above information is accurate and complete 2 you confirm that 1 the above information is you agree to the terms of this Agreement and accurate and complete and 2 you agree to accompanying document HOW LIFELINE WORKS the terms of this Agreement and and 3 you have been given the User Manual for the accompanying document HOW LIFELINE Lifeline equipment WORKS Signature of Subscriber Date Signature of Payer if different than subscriber Date PN 0940840 Rev 01 PHILIPS LIFELINE MONITORING SERVICES Care Plan Agreement Terms and Conditions HOW LIFELINE WORKS Welcome to2. only after you communicate them to Lifeline e Follow Lifeline s recommended procedures e Pay any fine resulting from a false alarm The Lifeline Service Relies on your Telephone Service to Operate f your telephone service is out of order or disconnected the Equipment will not operate until telephone service is restored Lifeline has no control over your telephone service And it will not know if your service is not working Therefore it cannot provide the Lifeline service during that time or notify your responders that your telephone service is out of order Also please be aware that using telephone service provided via the internet broadband VoIP or any other non traditional telephone service presents risks for non transmission of the signals from the Equipment to Lifeline s call center and the Equipment may not operate as intended Will Lifeline Work If My Phone is Off the Hook or I Lose My Dial Tone Your Equipment needs a dial tone to be able to contact Lifeline Even if your telephone service is working your telephone line can lose a dial tone if a phone is off hook or other devices are using the phone line To reduce the risk that your Lifeline Equipment will not have a dial tone you can ask your telephone company to install technology in your home such as an RJ31X jack to permit your Lifeline Communicator to seize the line and obtain a dial tone Lifeline cannot install an RJ31x or equivalent you must
3. power down your GoSafe Mobile Button prior to returning it for service Wireless Service Limitations The Wireless Equipment i may receive global positioning satellite GPS signals and ii communicates with Lifeline via wireless communications networks The availability of Wireless Service and use of the Wireless Equipment is subject to many limitations The Wireless Service will not work if a your Wireless Service subscription with Lifeline is not active b your Wireless Equipment does not have sufficient electrical power either battery or outlet c you are located outside the 50 United States or are outside the operating range of the Carrier s wireless network or d there is wireless network interference due to atmospheric or topographical conditions busy cells capacity limitations equipment problems equipment maintenance public utility failure acts of war government actions terrorism civil disturbances system failures including internet computer telecommunication or other system failures and other factors and conditions Lifeline assumes no liability for or relating to the delay failure interruption or corruption of any voice call quality or data transmitted while using the Wireless Service nor for the accuracy or precision of location information it provides to Responders Lifeline s Rights Lifeline has the right to disable Wireless Equipment or otherwise block access to the Wireless Service if you ar
4. 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 By signing this Agreement you agree that you are a Subscriber to and or Payer for the Service and have read this Agreement including the following What is the Lifeline service A Lifeline Communicator will be installed in your home and you will be given a Personal Help Button AutoAlert Help Button or GoSafe Mobile Button collectively Equipment Be sure to read the User Manuals for this Equipment If Lifeline s Response Center receives a Help Needed signal from the Equipment Lifeline will make a reasonable effort to promptly contact you If after making or trying to make contact Lifeline decides it is necessary in its reasonable judgment it will then notify the listed Responders in the order shown on the front of this Agreement or Police Fire or Ambulance How Lifeline Responds to Your Requests You agree that Lifeline may rely absolutely on statements made by you or your listed Responders or any person who says that they are acting on behalf of you or a Responder You agree that Lifeline is not responsible for the promptness sufficiency or adequacy of the action of any Responder or third party acting for a Resp
5. Addendum you as a Subscriber to and or Payer for the Wireless Service agree to the following additional legal terms and conditions What is the Lifeline Wireless Service The Lifeline Wireless Service works like the basic Lifeline service see How Lifeline Works with the following added features e your Equipment either a Lifeline Wireless Communicator and or GoSafe Mobile Button both the Wireless Equipment will be able to send a help signal to the Lifeline response center via a cellular signal if cellular service available e the optional GoSafe Mobile Button permits two way communications between you and our response center directly through a microphone and speaker built into your personal help button and e the optional GoSafe Mobile Button contains technology designed to help us approximate your location Wireless Location Tracking You understand that Lifeline attempts to track your approximate location whenever it receives a signal from your Wireless Equipment You authorize Lifeline to collect use disclose transmit process store and share this information to a provide maintain and improve the Wireless Service and Equipment and b in case of an Incident provide your location information to Lifeline s partners Responders third party service providers including emergency services and any person claiming to be acting on behalf of a Responder Lifeline does not guarantee that we can always tr
6. PHILIPS Lifeline Philips Lifeline Care Plan Agreement Page 1 of 2 O This is a PARTIAL Install Program Name Program Phone Number Installation Date LI This is a FOLLOW UP Install 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 Gender Date Of Birth Household Information Residential Street Address Apt LI Spanish Other CENTRAL DISPATCH CI Male Female Emergency Phone Numbers Do not list 911 or 800 s POLICE City Zip Code FIRE Township Municipality Household Hidden Key Location Directions To Home Must Be Provided If PO Box Listed PHB AAHB xmit code PHB AAHB exipiry Drug Allergies ALTERNATE AMBULANCE oO Check if Private AMBULANCE Subscriber Email Address Special Instructions Addl Svcs L State Funded O Lifeline Smoke Detector O Healthcare Directives Medical Conditions and or Diseases Household Warning Responder O Name First Last Responder Two Responder Two Name First Last Responder Three Name First Last Language Need LI Spanish Other Language Need LI Spanish J Other Language Need LI Spanish Other Street Address Street Address Street Address City Sta
7. ack your location due to the limits of the location tracking technology Your Responsibilities as a Subscriber or Payor of the Lifeline Wireless Service You understand that you must 1 Periodically recharge the battery of your GoSafe Mobile Button in accordance with the User Manual instructions The GoSafe Mobile Button contains an internal battery but will not work or be able to access the Wireless Service if the battery is allowed to discharge Lifeline does not take responsibility to notify you or your Responders if your GoSafe Mobile Button battery is low or becomes discharged P N 0940840 Rev 01 2 Follow the instructions for use in your User Manual and not use the Wireless Equipment or Wireless Service in a prohibited manner 3 Be responsible for providing Responders with access to the location you are in 4 Remain solely responsible for any use of your Wireless Equipment and Wireless Service even if you are not the one using it and even if you later claim the use was not authorized You are also solely responsible for anyone using or accessing the Wireless Service on your behalf 5 Not utilize the GoSafe Mobile Button if you have an implantable cardiac device such as a pacemaker or defibrillator 6 Power down your GoSafe Mobile Button prior to traveling on an airplane and ensure you power it back on when it is safe to do so 7 Notify Lifeline in advance of returning your Wireless Equipment for service and
8. cess code Payment Information You agree to pay the Fees shown in this Agreement along with any sales tax or additional Lifeline services you later order Fees are subject to change upon 30 days prior written notice to Payer Payment is due upon your receipt of an invoice Past due balances over 30 days are subject to a monthly finance service charge of 18 percent per year or the maximum allowable by law If Lifeline must institute legal proceedings to collect payments due then you agree to pay Lifeline s reasonable attorney s fees for such collection action unless prohibited by law You agree to pay for a full month of service for any month in which you have Service Lifeline reserves the right to charge a 50 00 fee for each replacement Personal Help Button or Auto Alert Help Button Term of Service Your Service starts when the Equipment is shipped Service must remain in effect for a minimum of THREE 3 MONTHS excluding Medicaid and other agency funded subscribers after which it may be terminated by either you or Lifeline for any reason by sending the other party 30 days prior written notice If Service is terminated you will return Equipment to Lifeline at your expense either by mail or arranging for pick up for a fee by a Lifeline representative If you do not return Equipment within 30 days after termination Lifeline reserves the right to charge you a 400 00 lost Equipment fee Lifeline makes no guarantee
9. do so Special Note about AutoAlert GoSafe Mobile f you order the AutoAlert Help Button or the GoSafe Mobile Button be aware that it will NOT detect all types of falls Therefore if you fall you should still try to press your button if possible How Lifeline Uses Your Personal Information You are providing Lifeline with health financial and other personal information so that Lifeline can provide services You agree that Lifeline Referral Source Program Responders and other parties named in this Agreement can receive that information You agree that if a Responder or other assistance is sent to subscribers home or elsewhere an ncident Lifeline may notify the parties listed in this Care Plan Agreement Communications between you and the Lifeline response center may be recorded and you consent to that recording Forced Entry You understand that if a help signal is received by Lifeline and a Responder is sent to your home Lifeline is NOT RESPONSIBLE and you relieve Lifeline of any liability for how the Responder chooses to enter your home For example if the Responder does not have or cannot find a key you hereby authorize the Responder to break into your home even if this causes damage If you have a hidden key location lockbox or garage opener you are responsible for maintaining the key or lockbox in an accessible location and informing Lifeline of any changes to the location of the key or the ac
10. e suspected of abuse or fraudulent activity Abuse and fraudulent use of Wireless Service include but are not limited to i attempting or assisting another to access alter or interfere with the communications of and or information about another Lifeline customer ii tampering with or making an unauthorized connection to the wireless network iii installing any amplifiers enhancers repeaters or other devices that modify the radio frequencies used to provide the Wireless Service iv subscription fraud v using Wireless Service in such a manner so as to interfere unreasonably with the use of the Wireless Service by one or more other subscribers or to interfere unreasonably with Lifeline s ability to provide the Wireless Service vi using the Wireless Service to convey obscene salacious or unlawful information vii using the Wireless Service without permission on stolen or lost Wireless Equipment viii Unauthorized Access and ix using the Wireless Service to provide voice over IP services and Lifeline shall not be liable for damages arising from or related to any abuse or fraud facilitated by you UNDER CERTAIN CIRCUMSTANCES SOME OR ALL OF THE WIRELESS SERVICE MAY BE SUSPENDED OR TERMINATED WITHOUT PRIOR NOTICE TO YOU AND WITHOUT ANY LIABILITY TO LIFELINE OR THE CARRIER Use of the Wireless Service is at your sole risk You acknowledge and agree that you have not relied on and are NOT entitled to the benefits of any re
11. less communications transmission and connectivity Wireless Service related to operation of the Wireless Equipment You understand and agree that you have no contractual relationship with the Carrier and you are not a third party beneficiary of any agreement between Lifeline and the Carrier You understand and agree that the Carrier has no liability of any kind to you whether for breach of contract or warranty in connection with use failure to use or inability to use the Wireless Service You have no property right in any number assigned to you or your Wireless Equipment and understand that any such number can be changed at any time by Lifeline and or the Carrier You understand that neither Lifeline nor the Carrier can guarantee the delivery privacy or security of wireless transmissions to and from the Wireless Equipment and neither will be liable for any lack of privacy or security relating to the use of the Wireless Equipment You may not resell the Lifeline service or any component thereof to any other party Signatures of Subscriber and if different Payer you agree to the terms of this Wireless Addendum WORKS document and 2 you have been provided with the User Manual for the Wireless Equipment P N 0940840 Rev 01 FOR SUBSCRIBER By signing below you confirm that 1 including the terms in the accompanying HOW LIFELINE Signature of Subscriber Date FOR PAYER if different than Subscriber B
12. onder You understand that Lifeline does not represent or guarantee that Responders can be contacted or will respond or that their response will be safe or effective You agree that the Responders have been designated by you and are not agents or representatives of Lifeline Your Responsibilities as a Subscriber You understand that you must e Provide electrical power and a functioning telephone connection to the Equipment The Equipment will not work if unplugged if telephone service is down during a power outage or if A C power P N 0940840 Rev 01 is not provided The unit has a backup battery that will work for a limited period of time Lifeline does not take responsibility to notify you or your Responders if your Equipment stops receiving power e Give accurate information about your Responders You represent that your Responders have agreed to act as Responders e Not alter or modify the Equipment e Not move Equipment from its original installation without Lifeline s prior authorization e Allow access for Lifeline representatives to inspect Equipment for maintenance or removing Equipment after termination e Not cause repeated false alarms otherwise Lifeline may discontinue your service e Be responsible for providing Responders with access to your home e Promptly inform Lifeline of any changes to the information provided in this Agreement All changes are solely your responsibility and become effective
13. presentations promises descriptions of services or other statement not specifically set forth in this Agreement You agree to hold harmless and defend Lifeline from and against any loss liability damage expense including attorney s fees or claims of third parties resulting from any use or misuse of the Wireless Equipment or Wireless Service by you or any third party using the Wireless Equipment or Wireless Service through you and from your breach of any of the terms of this Agreement Neither Lifeline nor the Carrier would have agreed to provide the Wireless Equipment or Wireless Service to you if you did not agree to this limitation End of Service If your Wireless Service subscription is cancelled or terminated you will return the Lifeline Wireless Communicator to Lifeline at your expense either by mail or arranging for pick up for a fee by a Lifeline representative Prior to returning the Wireless Communicator you will i contact Lifeline and arrange for the cancellation of your Wireless Service subscription and ii ensure that your Wireless Equipment is packaged for shipment in accordance with Philips instructions If you do not return the Wireless Communicator within 30 days after termination Lifeline reserves the right to charge you a 500 00 lost Wireless Equipment fee Relationship with Wireless Carrier You understand that Lifeline not you contracts with a wireless carrier Carrier to provide wire
14. s or warranties of any kind relating to the service and expressly disclaims all warranties whether express or implied written or oral with respect to the service and the Equipment including warranty of merchantability or fitness for a particular purpose LIFELINE S MAXIMUM LIABILITY ARISING OUT OF PROVIDING THE SERVICE INCLUDING WIRELESS SERVICE INCLUDING THE EQUIPMENT OR ITS USE WHETHER BASED ON WARRANTY CONTRACT TORT OR OTHERWISE SHALL NOT EXCEED ALL PAYMENTS RECEIVED BY LIFELINE FROM SUBSCRIBER UNDER THIS AGREEMENT In no event shall Lifeline be liable for special incidental or consequential damages Some states do not allow exclusion or limitation of incidental or consequential damages so those particular limitations may not apply to you This Agreement and any Addenda hereto together the Agreement is the entire Agreement between You and Lifeline No person installing servicing or otherwise dealing with Equipment is or shall be authorized to act for or bind Lifeline This Agreement supersedes all prior representations understandings or agreements between You and Lifeline and may be amended or revised at any time without prior notice to you by Lifeline at its sole discretion You agree that this Agreement will be governed by the laws of the Commonwealth of Massachusetts P N 0940840 Rev 01 PHILIPS LIFELINE MONITORING SERVICES Care Plan Agreement GoSafe HomeSafe Wireless Addendum By signing this
15. te Zip Code City State Zip Code City State Zip Code L Have Key L Family Caregiver L Notify Family Relation L Have Key L Family Caregiver L Notify Family Relation C Have Key L Family Caregiver L Notify Family Relation Phone Home O Work O Cell Phone Home O Work O Cell Phone Home O Work O Cell Phone Home O Work OI Cell Phone Home O Work O Cell Phone Home O Work O Cell Phone Home O Work O Cell Phone Home O Work O Cell Phone Home O Work O Cell Email Address Email Address Email Address PN 0940840 Rev 01 PHILIPS Lifeline Philips Lifeline Care Plan Agreement Page 2 of 2 Program Code Name First Last Subscriber Last Name First Name Notify Family Relation I Family Caregiver O Reminder Contact Household Phone Notify Name First Last Program Name Family Relation I Family Caregiver L Reminder Contact Phone O Home O Work O Cell Primary Physician Name First Last Phone O Home O Work O Cell Name First Last Phone O Home O Work O Cell Third Party Notify Fax Number Phone O Home O Work O Cell Phone Name First Last Fax Number Preferred Hospital Referral Source Phone Position Title Hospital Name Name First Last City State Phone REQUIRED
16. y signing below you confirm that you agree to the terms of this Wireless Addendum including the terms in the accompanying HOW LIFELINE WORKS document Signature of Payer if different than subscriber Date
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