Text Size: - + | Print Page | Email Page

Baptist Health Lexington Lifeline Enrollment Form

Baptist Health Lexington offers on-line enrollment for Lifeline to residents of Fayette and surrounding counties in Kentucky.

Simply complete the form below. Your Lifeline service will begin with one or two working days after we receive your form.

Please fill in all of the blanks. Complete information will make it easier for us to assist you.

Household Information

Subscriber Name:

Last Name Sounds Like:

Street Address / Apt #:

City:

State: Zip:

Birthday:

Sex:

M F

Home Phone:

Language Need?:

Directions to Home:

Health information

Preferred Hospital:

City, State / Province:

Physician Name:

Physician Phone:

Allergies:

Physical Limitations:

Heart	Diabetes
Oxygen	Walker
TTY/TDD	Hearing Impaired
Other

Responder Information

List up to 3 individuals who have agreed to respond. Responder 1 will be called if monitors are unavailable to communicate with you. If responders you list are unavailable local police, fire or ambulance will be dispatched.

Responder #1

Name (First / Last):

Street Address:

City, State, Zip:

Home Phone & Minutes Away:

Work Phone & Minutes Away:

Relationship:

Keys to home:

Yes No

Language Need?

Responder #2

Name (First / Last):

Street Address:

City, State, Zip:

Home Phone & Minutes Away:

Work Phone & Minutes Away:

Relationship:

Keys to home:

Yes No

Language Need?

Responder #3

Name (First / Last):

Street Address:

City, State, Zip:

Home Phone & Minutes Away:

Work Phone & Minutes Away:

Relationship:

Keys to home:

Yes No

Language Need?

Please Provide an Additional Person to Notify In An Emergency

Name (First / Last):

Relationship:

Home Phone:

Work Phone:

Billing Information

Name (First, Mid Initial, Last):

Mailing Address:

City / State / Zip Code:

Home Phone:

Work Phone:

Installation

Who should we contact to arrange an installation time?

Phone Number:

Comments

Any other information, questions or comments?