Aspirus Lifeline Application

Aspirus Lifeline

Medical Alert Service Application
Subscriber Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Gender:

MaleFemale
Landline Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Language Needs:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Service

Please select the service you are interested in.
Monthly Services:

$25 per month - Home Safe Standard Service (landline required).$38 per month - Home Safe Standard Service with Auto Alert fall detection button (landline required).$41 per month - Home Safe wireless service for those without a landline.$56 per month - Home Safe Standard Service with Auto Alert fall detection button for those without a landline.$45 per month - On-the-Go Mobile Medical Alert Service. One time $99.95 pendant fee.
Household Hidden Key Location for Emergency Services:
Brief summary
Medical Information:
Drug Allergies:
Medical Conditions and/or Diseases:
Emergency Contacts

List 3 most available and closest persons. Should they not be available, we will engage the assistance of Emergency Services.

END
Device Preferences and Set-Up:

Please note, Auto Alert (Automatic Fall Detection) Personal Help button and the On-the-Go Mobile button are only available on the nylon neck cord option.
Would you prefer to wear your waterproof Personal Help Button on a:

Nylon neck cord, as a necklaceWristband
What days and times of the week are convenient for installation?
Who is to be notified for installation date and time? (If different than subscriber)
Phone number for installation:
Aspirus Lifeline uses and discloses protected health information to provide, coordinate and manage Personal Emergency Response services. All equipment is the property of Aspirus Wausau Hospital and must be returned in good, clean condition to Aspirus Wausau Hospital Lifeline. Services will be deactivated when equipment is returned.
Signature of Subscriber (or person completing application):

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Date:
Additional charges:
Lost Personal Help Button Fee - $95
Lost Auto Alert Fall Detection Button Fee - $150

aspirus.org/lifeline
Should be Empty:

Aspirus Lifeline