Telehealth Collaboration to
Lower Readmissions

See AutoAlert in Action

LIFELINE AUTOALERT PATIENT INFORMATION

* Required Fields

*First Name:

*Last Name:

*Phone:

*Discharge Date:

*Address:

*City:

*State:

*Zip:

Notes:

WHO TO CONTACT

*First Name:

*Last Name:

*Phone:

*Relationship:

MY MED PAK PATIENT INFORMATION

*Patient is alert and oriented? YesNo

*Patient has been notified to expect a call about this program? YesNo

*Patient has access to insurance information? YesNo

*Patient is receiving assistance from caregiver/family member? YesNo

Notes:

STAFF INFORMATION

*Staff Name:

*Type Your Email:

ATTENTION STAFF

Remind family (or patient) that they will be receiving a call from Lifeline within a day of arriving home.
They are eligible to receive Lifeline Autoalert FREE for the first 60 days, at no risk - and, FREE installation.
Suggested statement: We are committed that your loved one be safe at home during the critical first 2 months. To support you we have partnered with Lifeline who is making this service free for the first 60 days. They will be calling you in a day or two to see if you want to use this important service.

TO SUBMIT REFERRAL

Select your name (If you do not see your name, please select "Not Listed" and type in your name).
Type in your email address.
Click "Submit Here" button.

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