651/ Dear Health Alert Applicant:

Transcription

1 651/ Dear Health Alert Applicant: Thank you for your inquiry regarding the HealthEast Health Alert Program. Health Alert is a variety of electronic systems that help individuals to continue to live independently in their homes. HealthEast Health Alert originated at St. Joseph s Hospital and has been serving the Twin Cities metro area and western Wisconsin communities since The Health Alert Personal Emergency Response Service is an electronic device leased to individuals for a nominal monthly fee. Pressing the Personal Transmitter, which can be worn on the wrist, around the neck or on a belt clip, activates the Help Console, which plugs into any modular phone jack. After requesting help by pressing the Personal Transmitter button, a Response Center Representative s voice will come over the speaker on the Help Console to make voice contact. The Representative will call the person(s) they are instructed to call. If you are unable to make voice contact, the Representative will call responders from the list you have provided. If a responder cannot be reached, the Representative will call 911. To subscribe, use our online application,fill out this application thoroughly and mail or fax it back to our office or call us at (651) and we will be happy to take your information over the phone. If you have questions you may call (651) during normal business hours. If using the enclosed application, once complete, you may mail the application and appropriate fees to: 1700 University Ave W. St Paul, MN If you wish to fax your application, our fax number is (651) You may pick up the Help Console equipment by appointment only at our office located in the HealthEast Corporate Tower (see map). Installation is an easy procedure, similar to connecting an answering machine. Please call 651/ for an appointment time. If you are unable to pick up the equipment, you will be called by the Health Alert staff to schedule a home installation, for which there is a $40.00 fee. First months monitoring fee: Basic Help Console -$39.50 per month Or Help Console with Reminders -$43 per month Or Wireless (Cellular) Console- $60 Or Mobile Unit (Cellular/GPS) - $50 per month Or Mobile Unit (Cellular/GPS) w/ Fall Detection -$65 per month Fall Detector, add l feature - $27/month You can have your monthly payment automatically deducted from your credit card or bank account. Simply fill out the appropriate attached form. If you do not wish to use this form of payment, we will send you a bill once per month. When you no longer need the Help Console and button, it must be returned to our office. There will be a $30 charge if we need to send a Health Alert Representative to pick up your equipment. Thank you. March 2009

2 Personal Emergency Response Service Subscriber Application Name: _ (First, Middle Initial, Last) Preferred Name: Last name sounds like: _ Telephone Number: (_) _- Birth date: _/_/ Sex: M F Street Address: Apt City: State: Zip: County: _ Language Spoken: _ W HERE DID YOU HEAR ABOUT HEALTH ALERT? Do you live in a facility where you need to dial an extra number to get an outside line? YES NO Medical History: List physical limitations/diagnosis: _ Allergies: Preferred Hospital: Phone: ( ) City: _ State: Physician Name: Phone: ( ) Failure to provide the above requested information may make it difficult for Emergency Personnel to respond to your emergency needs properly. Office use only. Date Received: _

3 RESPONDERS: Please list up to three people, in the order you would like them to be called. Three Responders are recommended but not required for service. All Responders should have a key for access to your home and you should ask for their agreement to serve as a Responder. We recommend that the Responders you list be able to respond within 15 minutes. Please do not use PAGER numbers. RESPONDER #1 Name: Relationship: _ Home Phone: ( ) Work Phone: ( )_ Cell Number: ( ) Language spoken: Has a key to your home? Yes No RESPONDER #2 Name: Relationship: _ Home Phone: ( )_ Work Phone: ( )_ Cell Number: ( )_ Language spoken: _ Has a key to your home? Yes No RESPONDER #3 Name: Relationship: _ Home Phone: ( ) Work Phone: ( ) Cell Number: ( ) Language spoken: Has a key to your home? Yes No

4 Please list a concerned person or Notify person (who helps with your affairs) we may contact if we would have concerns about your well being. This person will NOT be contacted as a Responder unless that person is listed on previous responder page. Name: Relationship: _ City: _ State: _ Zip Home Phone: ( ) Work Phone: ( ) Do you wish to pick up a Help Console at our office (for faster install)? *Yes **No Name of person picking up Help Console: _ Relationship: _ Phone: *you MUST call (651) for an appointment time to pick up a Health Alert Help Console. **if no, you would prefer a Health Alert Representative to schedule an appointment to install. Billing Information Who will be making payments for this service? Name: _ Address: City: _ State: Zip: Would you like your monthly payments deducted from your credit card or bank account? **No Yes (fill out appropriate form) Credit Card Bank Account **If you check NO, we will send a monthly bill to the address listed above. Are you receiving any financial assistance from the State or County? No Yes (check the program) MEMBER # Alternative Care Grant (ACG) Elderly Wavier CADI Other: Name of Worker: _Phone: ( ) *Existing coverage or pending application does not guarantee payment for Health Alert Services. Prior authorization must be obtained from your Case Manager or Financial Worker. Are you on a Hospice Program? Yes No Hospice Program Name Phone: ( )

5 Inactivity Alarm: The Health Alert Help Console offers a true 24 hour custom programmable inactivity clock that alerts the Response Center if the subscriber misses a preset check-in time. This is an optional feature. Yes, I would like my Check-in time(s) to be No, I do not wish to have the Inactivity Alarm feature. Personal Help Button Style Preference: Wristband (Not available on Mobile Unit) Necklace Belt Clip (Only available on the Mobile units) I understand that the above information will be used for: a. Providing information to emergency responding personnel and/or hospital to which I may be transferred, in order to determine proper treatment for me. b. Providing information to my physician regarding any emergency for which I needed to have help summoned. c. Providing information to Responders and/or Concerned Persons I have listed above, or which I later may amend. d. Providing information to any Health Care Agency that may provide services deemed necessary for continuity of care. e. Providing information to any third party payer source for the purpose of determining reimbursement potential. I understand I may revoke authorization to release information from my HealthEast Health Alert record at any time, except where HealthEast has already taken action in reliance on it. I understand that I am financially responsible to HealthEast Health Alert for payment of the monthly rental/service charge, enrollment fee, and/or installation fee. Signature of Subscriber/Guardian/Next of Kin Date _ Relationship of Other and reason Subscriber is unable to sign

6 HEALTH ALERT HELP CONSOLE OPTIONS: (Please check one) Basic Help Console: This standard Console unit is the simplest model we offer. This model plugs directly into the modular phone jack with your existing telephone connected into the back of the Help Console unit. Features for this model include: Automatic daily system self test 80 hour back up battery Monthly Rental is $39.50 Help Console with Reminders: This two-way communicator features an optional Reminder system allowing the subscriber or caregivers to record up to 6 reminder messages. Plugs directly into the modular phone jack with your existing telephone connected into the back of the Help Console unit. Features for this model include: Automatic daily system self test 24 hour back up battery Monthly Rental is $43 Fall Detector: The Fall Detector is an optional ADDITIONAL feature you can add to your service. When the Fall Detector senses a change in orientation and the impact from a fall, it will automatically send a signal to the Response Center indicating help is needed. Features include: Fall Detector weighs only 2.7 oz. Can be worn on the belt or around the neck on a lanyard Handy base stand for night-time use Monthly Rental is $26.00 Wireless (Cellular) Help Console: This module DOES NOT require a landline phone or internet service. It is an independent device and uses cellular signal in your area. It DOES NOT require the user to have a cell phone.. Features for this model include: Automatic daily system self test Remote answering for incoming phone call hour back up battery Optional Reminders feature Monthly Rental is $60 Mobile Device: This device works out in the community, not just at home. Features include: Can be worn around the neck or on a belt clip 36 hour standby battery life Lightweight- weighs under 2 ounces Optional built in Fall Detection (optional) Monthly Rental is $50 without Fall Detection Monthly Rental is $65 WITH Fall Detection

7 Automatic Bank Debit Form Request for monthly charges to automatically be taken out of my Bank account. Charges are taken out once a month on the 22 nd. I, (please print name), (Bank holder Name) Subscriber s name (if different from above) _ Authorize HealthEast to automatically deduct monthly charges from my bank account for the purpose of paying for my Health Alert service(s). Bank Holder Signature Relationship to Subscriber Phone # Date_ A Voided Check must be included with this form to process this request Any questions about bank account debits, please call (651)

8 Credit Card Deduction Form Request for monthly charges to automatically be taken out of my credit card. Credit cards are charged on the 22 nd of each month. I, (please print name), (Cardholder Name) Subscriber s name (if different than above) Authorize HealthEast to automatically deduct monthly charges from my credit card for the purpose of paying for my Health Alert service(s). My credit card information is as follows: Visa_ or Master Card Number --- Expiration Date _-_ Cardholder Signature Relationship to Subscriber Phone # _ Date_ Any questions about credit card deductions, please call (651)