Personal Emergency Lifeline Application

Posted 3 years ago

Lifeline Model options you may select include:

In Home Only – Landline required – MXD Landline – $25 monthly fee
The standard unit is an in home unit that requires a landline. No location tracking available. The emergency response address is your home address. *Landline Device does NOT work with Spectrum Landline carrier*

Cellular LTE In-Home Only Unit
Option 1- standard unit – $35 monthly fee
Option 2 – standard unit + fall detector – $40 monthly fee
The standard unit is an in home unit that requires NO landline. No location tracking available. The emergency response address is your home address.

On the Go – Mobile PERS
Similar to a Tic Tac box in size
One button to push on the unit for emergencies
This unit can travel with you wherever you go
GPS internal for location tracking
Without Fall Detector – $40 monthly fee
With Fall Detector included – $45 monthly fee

Terms and Conditions of applying – by submitting this form, you are agreeing to the following:

I understand that I am responsible for the care of the unit while in my possession, and for its safe return. I am
aware that if I no longer need the unit, it is not transferable to any other family member or acquaintance and I
will contact Connect America directly to arrange safe return of the unit. If the equipment or part of it becomes lost, stolen or
damaged beyond repair, my estate or I will pay the replacement cost listed below.

Standard In-Home Unit – Replacement Cost – $150.00
– Additional Help Button Replacement Cost – $45.00

Cellular In-Home Unit – Fall Detector Emergency Medical Alert System Replacement Cost – $270.00
– Additional Help Button Replacement Cost – $65.00

On the Go – Mobile PERS – Replacement Cost: $259.00

In the rare event my unit or its components malfunction, I should call Connect America to alert them, and I will contact a
family member or responder to check in on me until such time as an installer/technician is available to correct
the problem. I have read and fully understand and accept the guidelines and terms of the Connect America Program.

Hidden Key / Lockbox:

A hidden key is not a requirement, but is strongly suggested for emergency purposes when a responder,
EMT’s or police are unable to enter your residence. The subscriber understands if a call for help is received and the subscriber cannot answer the door for 1) listed responder, or 2) an emergency responder (police, EMT’s), responder may need to break into the subscriber’s home, possibly causing damage. The subscriber accepts these terms and agrees not to make any claim against the responder, Medical Center Foundation of Hartford or Connect America for damages caused by forced entry.

Apply Online

Who is the subscriber? (The person using the lifeline)

Subscriber First Name*

Subscriber Last Name*

Subscriber Date of Birth*

Gender*

Language Spoken*

Subscriber Phone Number*

A valid phone number is required.

Subscriber Cell Number

A valid phone number is required.

Subscriber Email*

A valid email address is required.

Subscriber Address*

Please answer the following medical background questions and provide us information on your doctor as well as preferred hospital

Allergies*

Known medical conditions (heart, high blood pressure, hearing loss, etc)*

Medication Physical Location (in your home)

Primary Care Doctor Name*

Primary Care Doctor Clinic Name*

Clinic Address*

Clinic Phone Number*

A valid phone number is required.

Preferred Hospital Name*

Hospital Address*

Hospital Phone Number*

A valid phone number is required.

Provide us with a family contact that should be called in case of an emergency, account issue or billing matter

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Contact Address*

Emergency Contact Phone*

A valid phone number is required.

Choose your lifeline model from our available options:

Lifeline Model Choice*

Do you need an additional lifeline for your spouse or another person in the home? ($10/Mo Charge will apply)*

Complete the following fields if your spouse needs a lifeline as well

Spouse Name

Spouse Date of Birth

Spouse Gender

Spouse Allergies

Spouse Known Medical Conditions

Spouse Primary Care Physician

Spouse Primary Care Clinic Name

Spouse Primary Care Clinic Address

Spouse Clinic Phone Number

A valid phone number is required.

Spouse Preferred Hospital

Spouse Preferred Hospital Address

Spouse Preferred Hospital Phone Number

A valid phone number is required.

Hidden Key / Lockbox Location or Pin*

Billing Contact (if other than self)

Billing Contact Name*

Billing Contact Phone*

A valid phone number is required.

Billing Contact Address

Installation Contact: Who shall we call when our installers are ready to install your CST unit?

Install Contact Name*

Relationship to subscriber*

Install Contact Phone Number*

A valid phone number is required.

Who shall we call in the event a lifeline is activated for a non-emergency need? Please list two contacts.

Responder 1 - Contact name*

Contact Address*

Main phone*

A valid phone number is required.

Work phone

A valid phone number is required.

Cell Phone*

A valid phone number is required.

How many miles away does this person live from the subscriber?*

Does this contact have keys to the home?*

Responder 2 - Contact name*

Cellphone*

A valid phone number is required.

Does the contact have keys to the home?*

Terms of conditions acceptance

Your Full Name*

Terms Accepted Date*

I agree to the terms and conditions listed above*

Yes