THEDACARE LIFELINE. Thank you for your inquiry regarding the LIFELINE program offered by Thedacare.

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1 THEDACARE LIFELINE Thank you for your inquiry regarding the LIFELINE program offered by Thedacare. LIFELINE is a personal response system, which links you via a landline telephone line, with emergency help. In the event you should need medical assistance or any assistance at all, help is available at the touch of a lightweight, waterproof button. There is an initial installation charge of $42.00 and a small monthly rental fee of $35.70 (This fee is for our basic unit only. See order form for additional equipment selections). Should you decide to subscribe to LIFELINE, attached are the application and lease agreement for you to complete, sign, and return to ThedaCare Lifeline, PO Box 8025, Appleton, WI Also, please include a check or money order for the installation and first month s rent, a total of $77.70 (basic equipment only). Personal information on the application will be kept at the Lifeline Monitor Station. It can be very reassuring to know help is close at hand should you need it. If you have any questions regarding the forms or would like further information, please do not hesitate to call me at (920) or (920) Our fax number to expedite the installation process is (920) (If faxing the application, the check can be picked up at the time of installation). Sincerely, Lori LeBlanc ThedaCare Lifeline Coordinator Enc.

2 LIFELINE APPLICATION Office use only Program Code Model Type Ser # Install PLEASE COMPLETE BOTH SIDES OF APPLICATION Name Date of Birth Address City (No PO boxes only fire numbers) Zip Code Township County Phone # ( ) Hospital Preference Primary Care Physician Phone# Medication Allergies Briefly explain any medical problems you might have (ie. Diabetic, uses walker, cane, arthritis) How many people are living in your household? **You may use someone living in your household as a RESPONDER but they must have a cell phone in order for Lifeline to get in contact with them when they are not in the home. RESPONDERS: These are any relatives, friends, or neighbors who will come to assist you if needed. They should live within a reasonable distance from your home (5-15 minutes). They should also have a key to be able to enter your home to assist you or know where a hidden key is located. If you choose to hide a key, please list directions on back of this form (this would also be given to emergent personnel to enter the home). 1. Name Home Phone #( ) Address Work Phone #( ) City & zip code Cell Phone# ( ) Relationship, if any Have Key Yes No 2. Name Home Phone #( ) Address Work Phone #( ) City & zip code Cell Phone# ( ) Relationship, if any Have Key Yes No 3. Name Home Phone #( ) Address Work Phone #( ) City & zip code Cell Phone# ( ) Relationship, if any Have Key Yes No Please continue on the back of this page.

3 OTHER INFORMATION LIFELINE APPLICATION Page 2 1. Person to contact for installation: self other If other, Name Phone # ( ) 2. In case of an emergency, whom would you want notified? Name Relationship to you Address Phone # ( ) 3. Who will be responsible for the monthly payment? Payment options include: a coupon booklet or debit/credit card. If you choose to use your debit/credit card, please include: Name on card Billing Address City/State/Zip Phone # Credit Card Number Expiration Date 4. If Social Services is making the monthly payments, please list your Case Manager s Name and phone number: 5. How did you learn about the service? Hidden Key Directions:

4 SUBSCRIBERS STEPS REQUIRED FOR INSTALLATION When your application is received and approved, the program coordinator w ill: 1) Contact you or your representative. 2) At that time an installer w ill be assigned and this information w ill be shared w ith you. A convenient installation date and time w ill be arranged betw een yourself and the installer. 3) Please arrange for at least one of your responders to be available for the installation of the Lifeline equipment and program orientation. Allow approximately 1 hrs. for the installation. Technical Information Please also be advised that if you have TIME WARNER, VONAGE, CHARTER, or any other voice-over IP phone provider, w e cannot guarantee reliable Lifeline service since they are not as stable as regular telephone service. This is strict ly a disclaimer that if your cable service is out, you w ill not have use of your Lifeline. We w ant to be sure that your Lifeline unit is alw ays functional w hen you need it. In order to install a Lifeline you must have a w orking landline phone jack. Cell phones w ill not w ork w ith Lifeline

5 Subscriber: ThedaCare LEASE AGREEMENT - LIFELINE Installation: Name: Subscriber #: Address: Installation Date: Monthly Charge: Phone Number : Installation Charge: $ tax (Non-Refundable) PREAMBLE ThedaCare Lifeline is a volunteer not-for-profit organization established to provide electronic home monitoring services to appropriate persons. This contract constitutes the entire agreement of ThedaCare Lifeline and its subscribers relative to the equipment and services provided by Lifeline. DEFINITION Where the term Lifeline is used, this shall mean ThedaCare Lifeline and the volunteers or employees of these organizations. PROVISIONS 1. The subscriber agrees to lease the equipment and the service for the above noted monthly charge. It is understood that this service is furnished at a minimal cost, sufficient to reimburse the hospital for expenses incurred. 2. Every effort will be made to maintain the current monthly charge. However, this charge is subject to change. 3. It is understood that the equipment is the property of the hospital. New or reconditioned equipment may be placed in the home for use, at the discretion of the hospital. It is also understood that no alterations or repairs may be made on the equipment by anyone other than authorized hospital personnel. Hospital's Obligations. Hospital agrees to: 1. Repair or replace malfunctioning equipment within 3 business days of notification of the malfunction; this shall not apply in situations where equipment malfunction is due to abuse or damage by subscriber or where equipment may be subject to continued abuse. In such cases, equipment shall be removed and this contract deemed canceled. 2. Make every reasonable effort to contact the subscriber' s designated responders. If unable to contact these individuals, personnel will contact appropriate emergency services. Subscriber's Obligations. 1. Provide the names, addresses and telephone numbers of the individuals who agree to act as responders for the subscriber and have acknowledged this willingness. 2. Provide safe and reasonable access to the subscriber' s premises by the hospital installers and service personnel. Adverse events, such as minor property damage, which may occur relative to volunteer activity will be ordinarily viewed as the subscriber' s responsibility.

6 3. Provide emergency access to the subscriber' s premises for responders, police, or other emergency personnel. 4. Pay the monthly rental for the use of the equipment pursuant to the terms of the hospital bill. 5. Pay for any damage to doors, windows, or other property necessitated by forceful entry of responders or emergency personnel in response to activation of the equipment. 6. Responsible for any loss or damage due to negligence, including defacing of the equipment (stationary unit, any wires attached to unit, personal help button with chain). A fee of $ will be charged for the Personal Help Button; a $ fee will be charged for the unit. 7. Pay a $ fee if the subscriber does not return the equipment to the hospital within 30 days after this agreement terminates. 8. Subscriber further acknowledges that using telephone service provided via the internet, broadband, VoIP, or any other non-traditional telephone service presents additional risks for non-transmission of signals from the Equipment and the Equipment may not operate as intended. RJ31X Jack Waiver If there is more than 1 telephone in my house, any telephone which is off the hook will prevent the HELP signal from being sent to Lifeline if the standard J201 jack is used. An RJ31X jack allows the Lifeline unit to seize the telephone line and send a HELP signal even if any telephone is off the hook. Installing an RJ31X jack is the responsibility of the subscriber if they so choose to have one installed. It is NOT the hospital' s responsibility to install an RJ31X jack in the subscriber' s home nor will ThedaCare be responsible if a HELP signal cannot be transmitted due to a phone being off the hook. It is recommended that this jack be installed by a qualified technician. Termination Either party may terminate this agreement by giving thirty (30) days written notice. If either party defaults, including failure to pay the monthly charges, the other party may terminate the agreement without notice. AS A SUBSCRIBER, I FOREVER RELEASE AND DISCHARGE ThedaCare Lifeline and its representatives from any liability that may result from the equipment being removed from my residence. I ALSO AGREE THAT THE TERMS AND CONDITIONS OF THIS AGREEMENT HAVE BEEN READ BY, OR TO ME. I UNDERSTAND THE TERMS AND CONDITIONS AND HEREBY AGREE TO THEM. Signed and executed on,, by: Subscriber: Date: Witness: Date: Lessor: Theda Care Date: Date Service to Begin:

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