Philips Lifeline Care Plan Agreement Address Massachusetts Details

A Philips Lifeline care plan agreement form is a legal document that outlines the specific terms and conditions of a care plan agreement between a service provider and a customer. The form includes information about the service provider, such as name, address, and contact information, as well as details about the care plan itself, including what services are provided, when they will be delivered, and how much they will cost. This form can help ensure that both parties understand their obligations and responsibilities under the care plan agreement. It may also be used in the event that there is a dispute between the parties about the care plan.

Before you complete philips lifeline care plan agreement, you will need to find out more in regards to the type of form you will work with.

QuestionAnswer
Form NamePhilips Lifeline Care Plan Agreement
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesamazon, where to send philips life care plan agreement, philips lifeline care plan agreement, Responder

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Philips Lifeline Care Plan Agreement

Page 1 of 2

This is a PARTIAL Install

Program Name

 

Program Phone Number

 

Installation Date

 

 

 

 

 

 

This is a FOLLOW-UP Install

 

 

 

 

 

 

Program Code

 

Household Phone #

Model Type

 

Unit #

 

Accessories

 

 

(

)

 

 

 

 

 

 

Salutation

Subscriber Last Name

 

First Name

Middle

Suffix

Preferred Name

 

Last Name Sounds Like

Language Need?

Gender

 

Date Of Birth

 

 

 

 

 

Spanish

Other

Male

Female

 

 

 

 

 

 

 

 

 

 

 

Household Information

 

Emergency Phone Numbers (Do not list 911 or 800 #’s)

 

Residential Street Address/Apt.#

 

 

CENTRAL DISPATCH (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICE

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRE (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Township/Municipality

County

 

AMBULANCE

Check if Private

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE AMBULANCE

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Household Hidden Key Location

Directions To Home (Must Be Provided If PO Box Listed)

 

Additional Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Healthcare Directives

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inactivity Alarm Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Instructions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Funded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lifeline Smoke Detector

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug Allergies

 

 

 

Medical Conditions and/or Diseases

 

 

 

 

 

Household Warning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R e s p o n d e r O n e

 

R e s p o n d e r T w o

 

R e s p o n d e r T h r e e

Name (First/Last)

 

 

 

Name (First/Last)

 

 

Name (First/Last)

 

 

 

 

 

 

 

 

 

 

 

 

Language Need?

 

 

 

Language Need?

 

 

Language Need?

 

 

Spanish

Other

 

 

Spanish

Other

 

Spanish

Other

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

Street Address

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City, State, Zip Code

 

 

City, State, Zip Code

 

City, State, Zip Code

 

 

 

 

 

 

 

 

 

 

 

Family Relation

 

Have Key

Family Relation

 

Have Key

Family Relation

 

Have Key

 

 

 

 

Family Caregiver

 

 

 

 

Family Caregiver

 

 

 

 

Family Caregiver

 

 

 

 

Notify

 

 

 

 

Notify

 

 

 

 

Notify

 

 

 

 

Reminder Contact

 

 

 

 

Reminder Contact

 

 

 

 

Reminder Contact

Phone

 

Home

Work

 

Cell

Phone

 

Home

Work

Cell

Phone

 

Home

Work

Cell

(

)

 

 

 

 

(

)

 

 

 

(

)

 

 

 

Phone

 

Home

Work

 

Cell

Phone

 

Home

Work

Cell

Phone

 

Home

Work

Cell

(

)

 

 

 

 

(

)

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Home

Work

 

Cell

Phone

 

Home

Work

Cell

Phone

 

Home

Work

Cell

(

)

 

 

 

 

(

)

 

 

 

(

)

 

 

 

All information contained in this report is considered private and confidential, and is intended solely for use by authorized Philips Lifeline representatives. PN 0930338 Rev. 04 (LMS)

Philips Lifeline Care Plan Agreement Page 2 of 2

Program Code Subscriber Last Name

First Name

Household Phone #

()

Program Name

 

 

 

Notify

 

 

 

 

 

 

 

 

 

 

Notify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First/Last)

 

 

Family Relation

Name (First/Last)

 

 

Family Relation

 

 

 

 

 

 

Family Caregiver

 

 

 

 

 

 

 

 

Family Caregiver

 

 

 

 

 

 

Reminder Contact

 

 

 

 

 

 

 

 

Reminder Contact

 

 

Phone

Home Work

Cell

Phone

 

Home Work Cell

Phone

 

Home Work Cell

 

 

Phone

Home Work Cell

 

(

)

 

 

(

)

 

 

 

 

(

)

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Physician

 

 

 

 

 

 

 

Third Party Notify

 

 

 

 

 

 

 

 

 

Name (First/Last)

 

 

 

 

 

Name (First/Last)

 

 

 

Fax Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

Name (First/Last)

 

 

 

Fax Number

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preferred Hospital

 

 

 

 

Referral Source

 

 

 

 

 

 

Hospital Name

 

 

 

 

 

 

 

 

Name (First/Last)

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State

 

 

Phone (REQUIRED)

 

Organization/Agency Name

 

 

Position/Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Multiple Subscriber Household

 

 

 

 

 

Street Address

 

 

City, State, Zip Code

 

 

(You must complete a separate Care Plan Agreement for each

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coupon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Additional Subscriber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

B

 

 

C

 

 

Subscriber Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payer Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name (If applicable organization name)

 

 

 

Last Name

 

 

 

 

 

Home Phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Work phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

Social Security Number

Medicaid Number

Monthly Fee(s)

 

 

One Time Fee(s)

 

 

Payment Frequency

Payment Method

Monitoring Service $

 

Enrollment Fee

$

 

Monthly

 

Invoice

Inactivity Service

$

 

 

$

 

Quarterly

 

Credit Card

$

 

 

 

 

 

 

Shipping & Handling

$

 

Yearly

 

Debit Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Card Type

 

Name (as it appears on Card)

 

Card Number

 

Expiration Date

Visa

 

 

 

 

 

 

 

 

Master Card

 

 

 

 

 

 

 

 

American Express

 

 

 

 

 

 

 

 

Discover

 

 

 

 

 

 

 

 

For Program Use Only (Not to be Entered by Data Entry)

Signature Of Subscriber

Date

Signature Of Payer (If Different)

Date

All information contained in this report is considered private and confidential, and is intended solely for use by authorized Philips Lifeline representatives. PN 0930338 Rev. 04 (LMS)

PHILIPS LIFELINE MONITORING SERVICES-CARE PLAN AGREEMENT

1.PARTIES AND SERVICES: The person named as Subscriber and the person named as Payer (which for purposes of these terms and conditions are collectively referred to as “Subscriber”) hereby contract with Program, listed on the front of this Agreement for the Philips Lifeline Medical Alert Service (the “Service”). The obligations of Subscriber and Payer are joint and several, which means that both of you are equally responsible for the obligations of the Subscriber under this Agreement.

The Service includes Philips Lifeline Equipment and Monitoring. (“Equipment” means a Lifeline home communicator and Personal Help Button. It may also include a Smoke Detector or other authorized Lifeline accessories if such accessories have been installed in Subscriber’s home. YOU DO NOT HAVE A SMOKE DETECTOR UNLESS YOU HAVE GIVEN SPECIAL INSTRUCTIONS TO RECEIVE A LIFELINE SMOKE DETECTOR AND THAT SMOKE DETECTOR HAS BEEN INSTALLED). Monitoring is provided through a Response Center. The Response Center may be operated by Program directly or by sub-contract with Philips Lifeline (The term “Program” includes Lifeline to the extent that it provides monitoring services for Program.

The Service includes receipt, analysis and response to alarm signals from Equipment. Upon receipt of a signal, Program will make reasonable effort to promptly contact Subscriber and if Program deems necessary in its reasonable judgment, notify Responders, in the order designated by Subscriber on the front of this Agreement, or Police, Fire or Ambulance (designated on the front of this Agreement). (Responders listed by Subscriber and Emergency numbers for Central Dispatch, Police, Fire or Ambulance identified by Subscriber are collectively referred to as “Responders”).

Subscriber agrees that Program may rely absolutely on the statements of Subscriber, Responders, or any person who says that they are acting on behalf of a Responder or Subscriber, with respect to the location and condition of Subscriber.

Subscriber agrees that Program is not responsible for the promptness, sufficiency or adequacy of the action of any Responder or any third party acting for a Responder. Subscriber agrees that Program in no way represents or guarantees that Responders can be contacted, can or will respond, or that any response will be safe or effective. Subscriber agrees that the Responders have been designated by him or her and are not agents or other representatives of Program.

2.TERM & TERMINATION: This Agreement starts when Equipment is installed and it may be terminated by either party by sending the other party thirty (30) days prior written notice. Program may terminate this Agreement at any time for non-payment of fees or abuse of the service. Upon termination, Subscriber will return Equipment to Program. Upon termination, Subscriber may elect to 1) Mail Equipment to the Program at Subscriber’s expense or 2) Pay the Program for either a) UPS pick-up or b) Removal by a Home Service Representative at the Program’s current rates for such services at the time the Equipment is removed. If Subscriber fails to return Equipment within thirty

(30) days following termination, then Subscriber agrees to pay Program in cash the fair market value of Equipment at the end of such thirty

(30) day period.

3.SUBSCRIBER DUTIES: The Subscriber must:

a.Provide and be responsible for suitable electrical and telephone service for installation and operation of Equipment.

b.Select and give accurate information as to all Responders. Subscriber represents that personal Responders have agreed to act as Responders.

c.Not alter or attempt repairs to Equipment.

d.Not move Equipment without Program’s prior written authorization.

e.Allow access for Program representatives to inspect Equipment, for maintenance, or removing Equipment after termination.

f.Not cause repeated or frequent inadvertent or any willful false alarms.

g.Provide Responders with access to Subscriber’s home.

h.Promptly inform Program of any changes to the information provided in this Agreement. All changes are the sole responsibility of Subscriber and shall become effective at the time of delivery to Program.

i.Test Equipment at least once a month with the Personal Help Button and otherwise follow recommended procedures established by Program.

j.Pay any fine resulting from a false alarm, including an Inactivity Alarm.

4.FEES: Subscriber agrees to pay the Fees associated with this Agreement along with any applicable sales tax or for any additional services later agreed to by the parties. Fees are subject to change upon thirty (30) days’ prior written notice to Subscriber. Payment is due upon receipt of invoice. Past due balances (over thirty (30) days past due) will be subject to a monthly finance service charge equal to eighteen (18%) percent per annum, or the maximum allowable by law. Program may terminate this Agreement for non-payment of fees and recover all payments due to Program. In the event that it shall become necessary for Program to institute legal proceedings to collect payments due under this Agreement then Subscriber agrees to pay Program’s reasonable attorney’s fees for such collection action except where prohibited by law. Subscriber agrees to pay for a full month of service for any month in which the Subscriber has Service.

5.TELEPHONE LINES and RJ31X JACK: If Subscriber has two or more telephones in his/her home using the same telephone number, and if one of these phones is in use or off the hook, the Equipment will not operate without a special connection, such as an RJ31X jack. If Subscriber would like this type of connection, it is the responsibility of Subscriber to have the telephone company install it.

6.INTERRUPTION OF SERVICE: Subscriber acknowledges that the Equipment sends its signals using electrical and telephone company lines which are wholly beyond the control of Program and IN THE EVENT TELEPHONE SERVICE IS OUT OF ORDER OR DISCONNECTED, THE EQUIPMENT WILL NOT OPERATE. Program does not assume any liability for interruption of the Service due to strikes, riots, sabotage, terrorist activities, floods, storms, earthquakes, fires, power failure, interruption of telephone service, acts of God, or any other cause beyond Program’s control including, without limitation, the activities of Subscriber. PROGRAM IS NOT REQUIRED TO SUPPLY THE SERVICE DURING THE CONTINUATION OF ANY INTERRUPTION OF TSERVICE DUE O ANY SUCH CAUSE. 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.

PN 0930338 Rev. 04 (LMS)

PHILIPS LIFELINE MONITORING SERVICES-CARE PLAN AGREEMENT

7.CONSENT TO DISTRIBUTION OF INFORMATION: Subscriber is providing Program with certain medical information for the purpose of providing the Service. Subscriber agrees that Program, Referral Source, Responders and any other party named in this Agreement all may receive the information contained in this Agreement or otherwise provided by Subscriber to Program or concerning the Service. Subscriber further agrees that in the event that a Responder or other assistance is sent to Subscriber’s home (an “Incident”) Program may notify any or all of the parties listed in this section. Further, Subscriber releases Program from all liability, which may arise out of Program’s disclosure of information in this Agreement or about any Incident to the parties listed in this section. Subscriber acknowledges that all communications between Subscriber and Response Center may be recorded and Subscriber consents to such recording.

By signing this agreement, Subscriber acknowledges that he/she has received a Notice of Privacy Practices as required under Standards for Privacy of Individually Identifiable Health Information; final Rule (45 CFR Parts 160 and 164). Subscriber consents to the use and disclosure of protected health and other information about them provided both on the Care Plan Agreement and created in the course of providing the service as follows: Treatment: Program uses and discloses protected health information to provide, coordinate, and manage Personal Emergency Response Services (PERS services). Program uses and discloses this information to third party health care providers and to other entities who need this information to ensure the provision of your PERS services. Payment: Your protected health information will be used as needed to obtain payment for your PERS or other related health care services. Healthcare Operations: Your protected health information may be used or disclosed as needed in order to support the business activities of Program or the hospital or healthcare providers who provide your Service or who referred you to the Service.

8.FALSE ALARMS OR ABUSE OF SERVICE: Subscriber agrees to reimburse Program for any fee assessed against Program as a result of false alarms originating from Subscriber’s premises which Program considers to be excessive.

9.FORCED ENTRY and INACTIVITY ALARMS: Subscriber agrees that if ANY ALARM SIGNAL is received by Program and a Responder is sent to Subscriber’s home and Subscriber cannot let Responder into the home and Responder does not have a key THE SUBSCRIBER AUTHORIZES RESPONDER TO BREAK INTO SUBSCRIBER’S HOME. SUBSCRIBER UNDERSTANDS THAT THIS MAY CAUSE DAMAGE TO THE HOME. SUBSCRIBER WAIVES ANY CLAIM AGAINST PROGRAM OR ANY RESPONDER, WHICH MAY ARISE AS A RESULT OF FORCED ENTRY INTO THE HOME. SUBSCRIBER SPECIFICALLY WAIVES ANY CLAIM FOR DAMAGE RESULTING FROM FORCED ENTRY AFTER AN INACTIVITY ALARM EVEN IF SUBSCRIBER IS SIMPLY NOT HOME.

10.ATTORNEYS’ FEES: In the event that it shall become necessary for Program to institute legal proceedings against Subscriber to

enforce any provision of this Agreement, Subscriber agrees to pay Program’s reasonable attorneys’ fees, except where prohibited by law.

11.ASSIGNMENT: This Agreement may not be assigned by Subscriber except with the prior written consent of Program.

12.WARRANTIES AND DISCLAIMER: Subscriber understands and agrees that Program is not an insurer and that insurance, if any, covering personal injury or other personal claims and property loss or damage on Subscriber’s premises shall be obtained by Subscriber in such amounts and covering such perils as Subscriber may determine; that Program is being paid to provide a Service and that the amounts being charged by Program are not sufficient to guarantee that no loss will occur; that Program is not assuming responsibility for any losses which may occur even if due to Program’s negligent performance or failure to perform any obligation under this Agreement. Subscriber assumes all risk of loss or damage to premises or the contents thereof, or personal injury.

PROGRAM MAKES NO GUARANTEES OR WARRANTIES OF ANY KIND RELATING TO THE SERVICE AND EXPRESSLY DISCLAIMS ALL WARRANTIES WHETHER EXPRESS OR IMPLIED, WRITTEN OR ORAL, WITH RESPECT TO THE SERVICE AND THE EQUIPMENT, INCLUDING ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. IF, NOTWITHSTANDING THE OTHER PROVISIONS OF THIS AGREEMENT, THERE SHOULD ARISE ANY LIABILITY TO PROGRAM, PROGRAM’S MAXIMUM LIABILITY ARISING OUT OF THE PROVISION OF THE SERVICE, INCLUDING THE EQUIPMENT, OR ITS USE, WHETHER BASED UPON WARRANTY, CONTRACT, TORT OR OTHERWISE, SHALL NOT EXCEED ONE-HALF THE ANNUAL PAYMENTS RECEIVED BY PROGRAM FROM SUBSCRIBER UNDER THIS AGREEMENT. SINCE IT IS IMPRACTICAL AND EXTREMELY DIFFICULT TO FIX ACTUAL DAMAGES WHICH MAY ARISE DUE TO A FAILURE OF THE SERVICE, THIS SUM SHALL BE COMPLETE AND EXCLUSIVE AND SHALL BE PAID AND RECEIVED AS LIQUIDATED DAMAGES AND NOT AS A PENALTY. IN NO EVENT SHALL PROGRAM BE LIABLE FOR SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES.

Subscriber has read and understands all of this Agreement, and Program’s maximum liability in the event of any loss, damage or injury to or death of, Subscriber.

Subscriber agrees to indemnify and hold harmless Program, its employees and agents from and against all third party claims, lawsuits and losses alleged to be caused by Program’s performance, negligent performance or failure to perform its obligations under this Agreement.

13.ENTIRE AGREEMENT/MODIFICATION: This Agreement shall constitute the entire Agreement between Subscriber and Program. No person installing, servicing or otherwise dealing with Equipment is or shall be authorized to act for or bind Program. This Agreement supersedes all prior representations, understandings or agreements between the parities. This Agreement may only be modified in writing signed by both parties. The parties agree that this Agreement will be governed by the laws of the Commonwealth of Massachusetts.

All information contained in this Care Plan is considered private and confidential, and is intended solely for use by the Subscriber, Program and

other authorized Philips Lifeline representatives as provided for in this Agreement. Lifeline is a registered trademark of Philips.

PN 0930338 Rev. 04 (LMS)

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