______________________________651/232-3560 Dear Health Alert MedReady 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 1981. The MedReady Medication Dispenser is the ideal solution for you if you have a complex medication schedule or have trouble remembering when to take your medication. The MedReady Medication Dispenser holds up to 28 doses of medication in the round tray at one time. The MedReady will beep and the red light will flash when it is time for the medication to be taken. Simply slide the door on the front open and scoop out your pills. The MedReady can dispense up to 4 times a day. The MedReady is light enough to be taken on vacations and trips. Simply unplug the MedReady from the A/C power and pack in your suitcase. It will continue to operate on back-up battery for close to 72 hours. When you get to your destination, simply reconnect to A/C power and the MedReady battery will recharge for next use. The MedReady is easy to program and load with medication. It can also be connected to the phone line and can notify a caregiver if there is a missed dose of medication. The monthly fee for the MedReady Medication Dispenser is $42.00

February 2014

To subscribe, either fill out this application thoroughly and mail or fax it back to our office or call us at (651)232-3560 and we will be happy to take your information over the phone. If you have questions you may call (651) 232-3560 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 55104. If you wish to fax your application, our fax number is (651) 232-4996. You may pick up the MedReady Medication Dispenser by appointment only at our office located in the HealthEast Corporate Tower (see map on back of page). Installation is an easy procedure, similar to connecting an answering machine. Please call 651/232-3560 for an appointment time. If you are unable to pick up the dispenser, you will be called by the Health Alert staff to schedule a home installation, for which there is a $40.00 fee. ☺ 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 MedReady Medication Dispenser, 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.

MedReady Medication Dispenser 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: _________________________

WHERE 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

CAREGIVERS: Please list up to two people, in the order you would like them to be called if there is a missed dose of medication. CAREGIVER #1 Name: ____________________________________

Relationship: ______________________

Home Phone: (

)_____________________

Work Phone: (

)______________________

Cell Number: (

)_______________________ Language spoken: ________________________

CAREGIVER #2 Name: ____________________________________

Relationship: ______________________

Home Phone: (

)______________________

Work Phone: (

)______________________

Cell Number: (

)______________________ Language spoken: ______________________

Office use only. Date Received: ______________________

Loading the Medication Please list the person responsible for loading the medication into the machine Name: ___________________________ Relationship to Subscriber:____________________ If this person is a home care nurse, please list the agency name and phone number: _____________________________________________________________________________

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) 232-3560 for an appointment time to pick up a MedReady Medication Dispenser **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 Other: __________________________________________

CADI

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.

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

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 22nd.

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______________________________________

Date________________

Relationship to Subscriber___________________________________ Phone #__________________________________________________

A Voided Check must be included with this form to process this request

Any questions about bank account debits, please call (651) 326-1415

Credit Card Deduction Form Request for monthly charges to automatically be taken out of my credit card. Credit cards are charged on the 28th 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 ________

Master Card ________

Discover ________

American Express ________

Number ____________-____________-____________-___________ Expiration Date _______-_______

Cardholder Signature_______________________________________

Date________________

Relationship to Subscriber___________________________________ Phone # _________________________________________________

Any questions about credit card deductions, please call (651) 326-1415.