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Government Referral Form

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16%

Referrer Information

Referral Type*

Case Manager Name*

First Last

Title

Organization

Email*

Phone*

Fax*

Member Contact Information

Full Name*

First Last

Client ID Number*

Date of Birth*

MM slash DD slash YYYY

Gender*

Phone*

Email

Spoken Language(s)

Other than English

Service Address*

* Please note that we cannot provide service to PO Boxes

Street Address Address Line 2 City State ZIP Code

Shipping Address

* Please note that we cannot ship to PO Boxes

Same as Service Address

Street Address Address Line 2 City State ZIP Code

Member Medical Information

Primary Diagnosis Code

Medical Conditions

Allergies

Primary Physician

NPI

Physician Phone

Physician Fax

Preferred Hospital

Hospital Phone

Case Manager

Insurance Provider

No abbreviations, please.

Requested Device

Select Devices

Medication Dispenser

Personal Emergency Response System (PERS)

Select Type of Medication Dispenser*

Monitored

Unmonitored

Select Type of PERS*

Home PERS

Mobile PERS

Smartwatch

Connection Type*

Landline

Cellular

Button Type*

Pendant

Wristband

Mobile PERS Options*

On the Go

On the Go Mini

Optional Add-Ons

Fall Detection

Voice Extension

Lockbox

Optional Add-Ons

Lockbox

Leather Holding Pouch (for members with a pacemaker)

Optional Add-Ons

Fall Detection

Lockbox

Lockbox Code

Lockbox Location

Hidden Key Location/Garage Code

Contact for Install

Only include if different from member contact information.

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Add 2nd Install Contact

Add Another

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Add 3rd Install Contact

Add Another

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Medication Filler

Only include if different from member contact information.

Name

First Last

Phone

Alt. Phone

Relationship to Member

Emergency Points of Contact

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Contact Type

Add 2nd Emergency Contact

Add Another

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Contact Type

Add 3rd Emergency Contact

Add Another

Full Name

First Last

Phone

Alt. Phone

Relationship to Member

Contact Type

Notes

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Call: 800-368-2925 | Fax: 800-548-7695 | Email: governmentservices@lifeline.com

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*Disclaimer: Fall detection, including AutoAlert, does not detect 100% of falls. If able, users should always press their button when they need help. Button signal range may vary due to differing environmental factors. HomeSafe buttons are waterproof up to one meter of water for 30 minutes. Refer to IFU for more details. On the Go pendants are water-resistant and require adequate cellular coverage. Pendant coverage is subject to the device location, environment, equipment, and facility conditions. The “#1” claim is based on the number of subscribers.

Caution: To reduce any risk of strangulation, Lifeline neck cords are designed to break apart under certain conditions. However, any cord worn around the neck can pose a strangulation risk, including the possibility of death and serious injuries. This may be of more concern to wearers in wheelchairs, using walkers, using beds with guardrails, or who might encounter other protruding objects upon which the cord can become tangled.