SHAWANO MEDICAL CENTER LIFELINE

Thank you for your inquiry regarding the LIFELINE program. LIFELINE is a personal response system, which links you via a landline or cell phone, to 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 $35.00. (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 Shawano Medical Center Lifeline, 309 N Bartlett St, Shawano, WI 54166. Also, please include a check or money order for the installation and first month’s rent, a total of $77.00 (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 (715) 526-7257. Our fax number to expedite the installation process is (715)526-7140. (If faxing the application, the check can be picked up at the time of installation). Sincerely, Carol Grosskreutz Shawano Medical Center Lifeline Coordinator Enc.

Equipment Order Form Equipment HomeSafe Landline

Description Basic Unit w/basic button

Price $35.00/mo

Additional Basic Button

2nd button for use in multi-member household

$10.00/mo

HomeSafe Landline w/Auto Alert Additional AutoAlert Button

Basic unit with AutoAlert button (Button that detects falls w/o having to be pressed) 2nd AA button for use in multi-member household

$45.00/mo

HomeSafe Wireless w/basic button

Unit to be used with any cell phone/no landline

$42.00/mo

HomeSafe Wireless w/AutoAlert

Unit to be used with any cell phone with an Auto Alert button

$48.00/mo

Voice Extension

Extension for use with base units

$10.00/mo

Key Lock Box

Box that holds a key for your home(one-time fee)

$29.95

Installation

One-time fee that includes on-going service

$42.00

TOTAL DUE

Revised 3/11/14

Order

$15.00/mo

$

LIFELINE APPLICATION Office use only Program Code ________ Model Type _________ Ser # ___________________ Install _________________ PLEASE COMPLETE BOTH SIDES OF APPLICATION

Name________________________________________M______F_____ 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.

LIFELINE APPLICATION Page 2 OTHER INFORMATION

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? ___________________________________________ 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: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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.

Shawano Medical Center

LEASE AGREEMENT - LIFELINE Subscriber:

Installation:

Name: ____________________________________

Subscriber #:

Address:

Installation Date:

_____________________________

_____________________________ Phone Number :____________________

Monthly Charge: Installation Charge: (Non-Refundable)

$42.00

PREAMBLE Shawano Medical Center 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 Shawano Medical Center Lifeline and its subscribers relative to the equipment and services provided by Lifeline. DEFINITION Where the term Lifeline is used, this shall mean Shawano Medical Center 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.

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 $100.00 will be charged for the Personal Help Button; a $750.00 fee will be charged for the unit.

7.

Pay a $750.00 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 Shawano Medical Center 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: Shawano Medical Center Date:____________