Healthcare Medical Alert Agreement

HEALTHCARE MEDICAL ALERT AGREEMENT

This Healthcare Medical Alert Agreement (the Agreement) is entered into between the Provider identified below and the Patient identified on this form for the provision of medical alert monitoring services, equipment, and related support subject to the terms and conditions set forth herein. Provider Name:

1. SERVICE SUMMARY

Description of services to be provided (monitoring, 24/7 response center, fall detection, mobile alerting, caregiver notifications):

2. PATIENT INFORMATION

Date of Birth:   Gender:

3. EMERGENCY CONTACTS

4. INSURANCE & BILLING

5. MEDICAL HISTORY

6. DEVICE, INSTALLATION & MAINTENANCE

The Provider will supply the medical alert device(s) as described above. Device ownership may be retained by Provider unless otherwise stated below. Patient agrees to permit Provider or its authorized representative reasonable access to install and service equipment at Patient's premises. Patient shall be responsible for maintaining power, network or cellular service, and promptly reporting faults or damage to the Provider.

7. FEES, PAYMENT, CANCELLATION

Patient agrees to pay all fees set by Provider for equipment, activation, monitoring, and any applicable recurring charges. Fees are due in accordance with the billing terms provided by Provider. Cancellations by Patient must be given in writing and are subject to any minimum term, early termination fee, or return-of-equipment charge described herein or in Provider's fee schedule.

8. CONSENT TO MONITORING, DISPATCH & NOTIFICATION

By checking the boxes below and signing this Agreement, Patient authorizes Provider to monitor signals from the Device, contact emergency services and/or dispatch public safety responders on Patient's behalf in the event of an emergency, and to notify the emergency contacts listed above.

I consent to 24/7 monitoring of my medical alert signals.

I authorize Provider to contact emergency medical services and/or law enforcement on my behalf when Provider reasonably believes such response is required.

I authorize Provider to share medical alert status and relevant medical information with the emergency contacts listed above.

9. RISKS, LIMITATIONS, AND BENEFITS

Patient acknowledges that the Device and monitoring services are not a guarantee of response within any set time period and that technical issues, power or network outages, or other failures may prevent alert transmission. Patient also acknowledges benefits including rapid notification of responders, assisted monitoring during medical events, and enhanced communication with caregivers. Patient accepts the limitations and assumes responsibility to maintain Device power and to seek alternative means of assistance if Device is nonoperational.

10. PRIVACY & HIPAA ACKNOWLEDGEMENT

Patient authorizes disclosure of protected health information necessary for Provider to perform monitoring and emergency notification services. Patient acknowledges receipt of Provider's privacy practices and understands that information may be shared with emergency responders, emergency contacts, and other individuals or entities as permitted by applicable law.

I acknowledge and consent to the privacy and information sharing terms described above.

11. AUTHORIZATION TERM AND REVOCATION

This authorization is effective on the date signed and remains in effect until revoked in writing by Patient or until the Agreement is terminated in accordance with its terms. Authorization Expiration Date (if any):

12. LIMITATION OF LIABILITY & INDEMNIFICATION

Provider's liability for claims arising from the provision of services or equipment shall be limited to direct damages not to exceed the total fees paid by Patient in the prior three months, except where prohibited by law. Patient agrees to indemnify and hold harmless Provider from claims arising from misuse, neglect, or modification of the Device by Patient or third parties.

I have read and acknowledge the limitation of liability and indemnification provisions above.

13. ADDITIONAL AUTHORIZATIONS & NOTIFICATIONS

By signing below, Patient certifies that the information provided on this form is accurate and complete to the best of their knowledge, that Patient has authority to enter into this Agreement, and that Patient has read, understands, and agrees to the terms and conditions set forth above.

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