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Home Health Alert Online Application
Health Alert - Online Application

 

Health Alert - Online Application
  1. 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


  3. Name of person completing this application*
    Enter the name of the person completing this application.
  4. Primary contact number*
    Enter your primary contact phone number.
  5. This is a *
    Select the type of contact number.
  6. Alternate contact number
    Invalid Input
  7. This is a
    Select the type of contact number
  8. E-mail address
    Enter a valid e-mail address.
  9. Relationship to subscriber*
    Enter your relationship to the subscriber.

  10. Subscriber information


  11. First name*
    Enter the subscriber's first name.
  12. Last name*
    Enter the subscriber's last name.
  13. Gender*
    Indicate the subscriber's gender.
  14. Date of birth*
    Enter the subscriber's date of birth.
  15. Primary language
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  16. Address*
    Enter the subscriber's address.
  17. City*
    Enter the city.
  18. State
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  19. Zip code*
    Please enter a valid zip code.
  20. Phone number*
    Please enter a valid phone number.
    xxx-xxx-xxxx
  21. Preferred hospital
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  22. Physician name
    Invalid Input
  23. Physician phone number
    Invalid Input
    xxx-xxx-xxxx
  24. Please list your current medical information and any medication allergies:
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  26.  
  1. 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


  3. Responder Information


  4. 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.

  5. First responder name(s)
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  6. Relationship to subscriber
    Invalid Input
  7. 1st phone number
    Invalid Input
  8. 2nd phone number
    Invalid Input
  9. 3rd phone number
    Invalid Input

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  11. Second responder name(s)
    Invalid Input
  12. Relationship to subscriber
    Invalid Input
  13. 1st phone number
    Invalid Input
  14. 2nd phone number
    Invalid Input
  15. 3rd phone number
    Invalid Input

  16. Invalid Input
  17. Third responder name(s)
    Invalid Input
  18. Relationship to subscriber
    Invalid Input
  19. 1st phone number
    Invalid Input
  20. 2nd phone number
    Invalid Input
  21. 3rd phone number
    Invalid Input

  22. Invalid Input

  23. Next of kin

  24. Name
    Invalid Input
  25. Relationship to subscriber
    Invalid Input
  26. Phone number
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  27.  

  1. 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



  3. Equipment

  4. Select your product(s)


  5. Select your desired product(s).
  6. If you selected the Health Alert service above, please select your desired level of service:Choose a 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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  10. 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

  12. Includes all features for basic service, plus:
    • Does not require a telephone line or high speed data connection
    • Real-time clock display
  13. Current phone service provider
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  14.  
  15. 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.

  16. Additional Health Alert Services

  17. 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
  20. Installation


  21. Choose an installation option.
  22. Installation contact person*
    Enter the name of the contact for installation.
  23. Primary contact number*
    Enter the primary contact phone number.
  24. This is a*
    Select the type of contact number.
  25. Alternate contact number
    Invalid Input
  26. This is a
    Select the type of contact number
  27. Please list any special instructions:
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  29. 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.

  30. *
    You must select a billing option.


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  32. Name*
    Enter the name of the person who should receive the bill.
  33. Address*
    Enter the complete address.



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  35. Insurance type*
    Enter the insurance type.
  36. Case manager name and phone:*
    Enter the case manager's name and number.
  37. Client ID#:*
    Enter the client's identification number.

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

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