Health Alert

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Health Alert

Health Alert - Online Application

HealthEast Health Alert accepts applications online. If you have questions or would prefer to complete the application process by phone, call 651-232-3560.

*Required fields



Name of person completing this application*
Enter the name of the person completing this application.

Primary contact number*
Enter your primary contact phone number.

This is a *
Select the type of contact number.

Alternate contact number
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This is a
Select the type of contact number

E-mail address
Enter a valid e-mail address.

Relationship to subscriber*
Enter your relationship to the subscriber.

Subscriber information

First name*
Enter the subscriber's first name.

Last name*
Enter the subscriber's last name.

Gender*
Indicate the subscriber's gender.

Date of birth*
Enter the subscriber's date of birth.

Primary language
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Address*
Enter the subscriber's address.

City*
Enter the city.

State
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Zip code*
Please enter a valid zip code.

Phone number*
Please enter a valid phone number.

xxx-xxx-xxxx

Preferred hospital
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Physician name
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Physician phone number
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xxx-xxx-xxxx

Please list your current medical information and any medication allergies:

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HealthEast Health Alert accepts applications online. If you have questions or would prefer to complete the application process by phone, call 651-232-3560.

*Required fields



Responder Information


Please list your Responders below. "Responders" are your local friends, family members or neighbors who can assist you if you need help. Local Emergency services are always listed on the account automatically. There is no need to list them here.

First responder name(s)
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Relationship to subscriber
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1st phone number
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2nd phone number
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3rd phone number
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Second responder name(s)
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Relationship to subscriber
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1st phone number
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2nd phone number
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3rd phone number
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Third responder name(s)
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Relationship to subscriber
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1st phone number
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2nd phone number
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3rd phone number
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Next of kin

Name
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Relationship to subscriber
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Phone number
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HealthEast Health Alert accepts applications online. If you have questions or would prefer to complete the application process by phone, call 651-232-3560.

*Required fields



Equipment

Select your product(s)*

Select your desired product(s).

If you selected the Health Alert service above, please select your desired level of service:

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  • Automatic daily system self test
  • 24–hour rechargeable back–up battery
  • Adjustable volume controls

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Includes all features for basic service, plus:
  • Record up to 6 reminder messages
  • Reminders can be daily or one—time only
  • Reminders can be programmed directly on unit or remotely

Choose a level of service.

Includes all features for basic service, plus:
  • Does not require a telephone line or high speed data connection
  • Real-time clock display

Current phone service provider
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Please note: internet-based phone services, such as Vonage and Magic Jack, may not work with Health Alert service. Contact our office if you have questions about phone service.

Additional Health Alert Services

You may add a Fall Detector to your service, if you wish. Check the box below to add a Fall Detector to your service.

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  • Lightweight device is worn on the waist via a belt clip
  • Two-stage detection process provides reliable, fast detection to minimize false alarms
  • Handy base stand for night-time storage

Installation

Choose an installation option.

Installation contact person**
Enter the name of the contact for installation.

Primary contact number*
Enter the primary contact phone number.

This is a*
Select the type of contact number.

Alternate contact number
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This is a
Select the type of contact number

Please list any special instructions:

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Billing information

Health Alert service is billed once a month and there is no contract for service. Please indicate how you would like to pay for your Health Alert service.

Please note: Only county assistance programs, MSHO programs and MSC Plus insurance programs will pay for Health Alert Services. Medicare does NOT provide coverage for Health Alert Services.

*
You must select a billing option.

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Name
Enter the name of the person who should receive the bill.

Address
Enter the complete address.

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Insurance type
Enter the insurance type.

Case manager name and phone:
Enter the case manager's name and number.

Client ID#:
Enter the client's identification number.

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†Your credit card or bank account information will be collected at the time of installation.

Please let us know how you heard about HealthEast Health Alert:

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