Healthcare PERS Picklist

Healthcare PERS Picklist

Patient Information

Date of Birth:    Gender:    Phone:

Emergency Contact

Phone:    Relationship:

Insurance / Billing

Policy Number:    Group Number:    Subscriber Name:

Medical History / Considerations

PERS Equipment Picklist

Select required equipment and indicate quantity where applicable. Quantities default to one if not specified.

Monitoring & Notification Preferences

Select how alerts should be handled. Primary monitoring center will respond as described below unless superseded in writing.

24/7 Professional Monitoring

Notify Family / Emergency Contact First

Notify Primary Healthcare Provider

If notify family or provider, name of primary contact: Phone:

Authorization, Risks, and Acknowledgments

I, the undersigned, request the Personal Emergency Response System equipment and services indicated above. I authorize activation of PERS equipment and enrollment in monitoring services. I understand the purpose, limitations, and potential risks of PERS equipment, including but not limited to technical failure, delayed communication due to cellular or network interruptions, battery depletion, or improper use of the device.

I acknowledge that PERS is not a substitute for immediate professional medical care. In an emergency, I should call local emergency services if able. I consent to the release of necessary medical and billing information to the monitoring center, installation personnel, and authorized payers for the purposes of providing and servicing PERS. This authorization includes disclosure of contact and location information when needed to respond to alerts.

I understand that I may withdraw this authorization at any time by providing written notice to the provider, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: unless earlier revoked in writing.

Financial Responsibility: I agree to pay charges not covered by insurance or other payers, including equipment, installation, monitoring fees, and replacement costs for lost or damaged devices, as governed by the service agreement. I authorize billing to the insurance and/or the individual identified above.

Liability Release: To the extent permitted by law, I release the equipment provider and monitoring center from liability for failures in service or response except in cases of willful misconduct or gross negligence. This release does not affect statutory rights or remedies.

HIPAA / Privacy Acknowledgment: I acknowledge that I have received or been offered the facility's notice of privacy practices describing how my protected health information may be used and disclosed in connection with PERS services.

Provider / Equipment Tracking (For Office Use)

Installation Date:    Equipment Model(s) / Serial Number(s):

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