LifeFone At-Home & On-The-Go VIP Flex User’s Guide 5
STEP 3
Your Emergency Care Plan Agreement authorizes
LifeFone to respond properly in the event of an
emergency.
WE MUST RECEIVE YOUR SIGNED SERVICE
AGREEMENT WITHIN SEVEN (7) DAYS FROM
YOUR ORIGINAL RECEIPT TO ENSURE THE BEST
PROTECTION POSSIBLE.
Enclosed are two (2) copies of your
Emergency Care Plan Agreement.
Make sure to review all of the
information in this document
carefully to ensure accuracy.
Once you’ve conrmed that all of
the information on your Agreement
is correct, please sign and date the
bottom of the Agreement where
indicated, and return it to us in the
prepaid envelope provided. Please
keep the yellow copy for your
own personal records.
Complete and Mail Back the
Enclosed Emergency Care Plan
LifeFone Emergency Care Plan Agreement
1. SUBSCRIBER
7. ACCEPT AGREEMENT
2. PAYER (if different from subscriber)
16 Yellowstone Avenue, White Plains, NY 10607-1324 Phone: 1-800-882-2280 Fax: 1-800-747-2032
Fax this form to: 1-800-747-2032
SEE REVERSE SIDE FOR TERMS AND CONDITIONS OF THISAGREEMENT. READ THEM BEFORE YOU SIGN THIS AGREEMENT. SUBSCRIBER
ACKNOWLEDGES THAT HE/SHE HAS RETAINED A COPYOF THIS AGREEMENT. THIS AGREEMENT MAY BE CANCELLED WITH OR WITHOUT
CAUSE ATANY TIME PRIOR TO MIDNIGHT OF THE SEVENTH BUSINESS DAYAFTER SIGNATURE OF THE AGREEMENT.
Subscriber Signature Date Payer Signature (if not Subscriber)
Date
3. HIDDEN KEY AND LOCK BOX
Complete and return this agreement within 48 hours after receipt of equipment.
Return white copy of this agreement in the prepaid envelope. Call with questions 1-800-882-2280 x407
.
Unit ID: ________________ Entered: _________ Operator : ____________ Rep: _____________ Account #: _____________
THIS SECTION FOR OFFICE USE ONLY FOR PUBLIC SAFETY RESPONDERS: Uselocal phone number below — do not enter 911
6. SPECIAL INSTRUCTIONS
First Name:
Last Name:
Street Address:
Apartment/Floor:
City: State: Zip:
County/Township:
Nearest Cross Street:
Home Phone: ( )
Alternate Phone: ( )
Email:
Date of Birth: Gender: ❑ Male ❑ Female
First Name:
Last Name:
Mailing Address:
City: State: Zip:
Phone 1: ❑ Home ❑ Work ❑ Cell
( )
Phone 2: ❑ Home ❑ Work ❑ Cell
( )
Email:
Relationship to Subscriber:
5. MEDICAL AND PERSONAL INFORMATION
LF0621-OTG-MA
4. PERSONAL RESPONDERS (List in priority order 1-4. Indicate phone type. Select text/email notification option.)
Is Subscriber Ambulatory? ❑ Yes ❑No Check all that apply: ❑ Walker ❑ Cane ❑ Wheelchair ❑ Scooter
Hidden Key Location: Lock Box Code:
Police: ( ) Fire: ( ) Ambulance: ( )
1. Name:
Relationship: Keyholder:
Email Address:
Phone 1: ( )
Phone 2: ( )
3. Name:
Relationship: Keyholder:
Email Address:
Phone 1: ( )
Phone 2: ( )
❑ Yes ❑ No
❑ Yes ❑ No
Indicate Phone Type,and Select to have TEXT notification of Emergency Dispatch sent to Cell
Indicate Phone Type,and Select to have TEXT notification of Emergency Dispatch sent to Cell
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
2. Name:
Relationship: Keyholder:
Email Address:
Phone 1: ( )
Phone 2: ( )
4. Name:
Relationship: Keyholder:
Email Address:
Phone 1: ( )
Phone 2: ( )
❑ Yes ❑ No
❑ Yes ❑ No
Indicate Phone Type,and Select to have TEXT notification of Emergency Dispatch sent to Cell
Indicate Phone Type,and Select to have TEXT notification of Emergency Dispatch sent to Cell
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
❑
Home ❑
Work ❑
Cell
❑
Send Text Notifications
Allergies:
Preferred Hospital:
Hospital City and State:
Hospital Phone Number: ( )
Primary Care Physician Name:
Physician Phone Number: ( )
Height: Weight: Hair Color: Ethnicity: Preferred Language:
VEHICLE INFO: Make: Model: Color: Year:
Medical Conditions/Physical Limitations:
Medications:
❑
Send Email
Notifications
❑
Send Email
Notifications
❑
Send Email
Notifications
❑
Send Email
Notifications
