Healthcare Medical Pendant Contract

HEALTHCARE MEDICAL PENDANT CONTRACT

Parties and Patient Information

Provider Name:

Provider Address:

Insurance and Billing

Device and Services

Equipment Provided: One medical alert pendant with model/serial:

Included Services:

24/7 Monitoring and Emergency Dispatch

Automatic Fall Detection (if equipped)

Two-Way Voice Communication

Fees, Payment and Deposit

Monthly Service Fee:

One-Time Equipment Fee / Security Deposit:

Billing Method:

Late Payment and Collection: Fees not received within 30 days of invoice are subject to a late fee and collection costs as permitted by law.

Term, Termination and Return

Contract Term: This agreement commences on the date of activation and continues on a month-to-month basis until terminated by either party with thirty (30) days written notice.

Return of Equipment: Upon termination the patient must return the pendant and any accessories in good condition within 14 days. Damages beyond normal wear may incur repair or replacement charges.

Maintenance, Replacement and Repairs

Provider shall supply routine maintenance and, where applicable, battery replacement as part of the service. Lost or intentionally damaged pendants are the responsibility of the patient and may be billed at replacement cost.

Client Responsibilities and Use

The patient agrees to wear or carry the pendant as instructed, to keep contact information current, and to test the device as recommended. Misuse or tampering voids warranties and may result in fees for repair or replacement.

Medical History and Current Medications

Risks, Benefits, and Consent

Patient acknowledges that the pendant is a notification device and not a guarantee of emergency response. Benefits include timely notification to emergency responders and contacts. Risks include device failure, communication interruptions, and inadvertent activations.

Patient has had the opportunity to ask questions about the device, services, fees, and potential risks and hereby consents to receive the described equipment and services under the terms of this agreement.

Privacy, HIPAA and Authorization to Release Information

By signing below the patient authorizes the provider to collect, store, and transmit personal and medical information necessary for monitoring and emergency response. Provider will maintain confidentiality consistent with applicable privacy laws. Patient authorizes disclosure of relevant health information to emergency responders and the designated emergency contact when necessary for treatment or safety.

Acknowledgement: I acknowledge receipt of the provider's privacy practices and consent to the release and use of my information as described.

Limitation of Liability and Indemnification

Provider's liability for any claim arising out of or relating to this agreement, equipment, or services shall be limited to direct damages not to exceed the total of paid fees during the prior three (3) months. Provider is not liable for indirect, incidental, special, punitive or consequential damages. Patient agrees to indemnify and hold harmless the provider and its agents from claims arising from the patient's misuse of the device or false activation.

Governing Law and Dispute Resolution

This agreement shall be governed by the laws of the state in which the patient resides. Any dispute will first be submitted to non-binding mediation; if unresolved, either party may pursue legal remedies in the appropriate court.

Notices and Contact for Service

Notices required under this agreement shall be in writing and delivered to the addresses listed above. For questions or service requests contact:

Authorization Expiration

This authorization for release and use of information and provision of services will expire on:

Acknowledgment

By signing below the patient and provider acknowledge and agree to the terms and conditions contained in this Healthcare Medical Pendant Contract. The patient certifies that the medical information provided in this form is accurate to the best of their knowledge.

Sign Now