More than a bracelet, - MedicAlert Foundation

About MedicAlert
Foundation
An international charity, MedicAlert Foundation
was established in 1956 and pioneered the
use of medical identification and information
services for medical emergencies. We protect
the health and well-being of millions worldwide
through our trusted 24/7 emergency support
network. We educate emergency responders
and health professionals - our partners in
everyday emergency situations - about the
services we provide during emergencies. And,
we communicate your health information,
your wishes, and your directives to ensure you
receive the best care possible.
WEB www.medicalert.org
CALL 1.800.432.5378
More than a bracelet,
TM
it’s a safety network.
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Our services ensure emergency responders and
hospital staff get your up-to-date medical information,
the moment they need it, to make informed decisions
about your treatment and care.
With MedicAlert Foundation, you can be confident
knowing that you are connected to our 24/7 support
network – because every moment matters.
MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2014 All rights reserved.
MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation
International. Safe Return® is a U.S. registered trademark and service mark of the
Alzheimer’s Association.
10349E Rev.10
A MedicAlert® Membership To Fit Your Needs
Individual Memberships
Simplified
Online-Only Plans
Essential
TM
For Your Child
For Adults
For Adults with Alzheimer’s or Dementia
Kid Smart® Advantage In an emergency, we convey your
child’s health information to emergency
responders and health professionals
to ensure your child receives quick
and proper treatment. Kid Smart®
membership also includes 24/7 Family
Notification so that you are notified and
quickly reunited with your child.
We provide a medical record which is
available 24/7 to you (for unlimited
updates and review) and to professionals
to ensure your entire health history is
communicated when it’s needed. We also
connect with your loved ones so you may
be quickly reunited during an emergency,
and notify your Physician/Provider to
improve overall care coordination.
We understand the fears that weigh on
parents’ minds - We’re here to alleviate
those fears so you may rest easy and
your child can focus on fun.
Our comprehensive suite of 24/7
services allows you to enjoy today and
live worry-free.
MedicAlert® + Alzheimer’s
Association Safe Return®
6 out of 10 people with Alzheimer’s
or dementia will wander or become
lost. Should your loved one wander,
MedicAlert Foundation will work with
you, your local Alzheimer’s Association
chapter, and local law enforcement
to provide for the safe return of your
loved one.
You can’t know when a wandering
incident will happen, but you’ll know
what to do when it does.
Packaged Memberships
Connect Yourself to Your Loved One
Connect Your Entire Family
Caregiver Membership Family Membership What happens to your loved one should you
experience an emergency? We can contact your
designated back-up caregiver to keep your loved
one safe - this allows you to focus on your personal
recovery and overall health.
Keeping your family’s important health information
stored in one secure location can be an invaluable tool
for parents. Additionally, in the event of an emergency or
disaster situation, we can serve as your family’s single
connection, ensuring you are all quickly reunited.
www.medicalert.org/caregiver
www.medicalert.org/family
A streamlined
membership plan,
Essential offers the
convenience of a secure
health information
platform. In an emergency, Essential members
also receive MedicAlert’s signature service
offering - our live 24/7 emergency response.
Keeping track of your health can be
complicated - Essential offers security and
simplicity.
Advance
Directive
Management
Service (ADMS)
Our Advance Directive
Management Service will store your notarized
documents and make them available to health
professionals or a designated family member/
healthcare proxy in the event of an emergency.
We also provide the official advance directive
forms recognized by each state.
Ensure your healthcare wishes are honored
and spare your family the burden of making
difficult treatment decisions on your behalf.
online only plans
Kid Smart® www.medicalert.org/kidsmart
$40/year
Advantage www.medicalert.org/advantage
$50/year
Safe Return® www.medicalert.org/safereturn
$55/year
Essential TM
www.medicalert.org/essential
$10/year
24/7 Emergency Response
24/7 Family Notification
Add on: $15/year
24/7 Physician/Provider
Notification
Add on: $15/year
EMIR® (Emergency Medical
Information Record)
Call Center Concierge
Specialized Medical ID Offer
with Enrollment
Add on: $20/year
Free basic medical ID* or
$10 towards any ID purchase
Free basic medical ID*
Free Engraving on Medical IDs
Free downloadable card and
$5 for a plastic card
Emergency Wallet Card
Care Consultation Services
Advance Directives Storage
DNR Orders
Implanted Device Registration
Wandering Assistance
Global Service
Pet Caregiver Notification
*See back for free ID options
Add on: $15/year
Add on: $15/year
Add on: $15/year
Add on: $15/year
ADMS www.medicalert.org/adms
$10/year
MedicAlert® Medical IDs & Enrollment Form
go online www.medicalert.org, call 1.800.432.5378 or mail to PO Box 21009, Lansing, MI 48909
Visit www.medicalert.org/shopids to see full medical ID selection. Prices shown are subject to change without notice.
free with kid smart®
free with safe return®
red steel bracelet ($10)
purple steel bracelet ($10)
other id options (see all at www.medicalert.org/shopids)
black sports band ($25)
Iridescent Crystal
Bracelet ($60)
A126
Shoe Tag ($10)
A797
A661
stainless steel stretch
band ($30)
Standard Z102
Large Z101
A756
rhodium silver
bracelet ($100)
purple pendant ($10)
black dog tag ($10)
Small A734
Large A733
blue beaded bracelet ($30)
A117
large sterling silver bar
bracelet ($170)
A600
child’s steel bracelet ($10)
A156
Z100
A700
A195
ID Engraving: In an emergency, response personnel need to be aware of your critical
medical information in order to treat you correctly. We will personalize your medical ID
with your critical medical information and your unique MedicAlert member number after
we have reviewed your information. Only authentic MedicAlert medical IDs with the words
“MEDIC ALERT” use this review process. No other company provides this free service. We
may contact you if we have questions about the information you have provided.
Sample engraving of a personalized MedicAlert ID.
Please Note: Once your MedicAlert ID has been engraved and shipped, there will be an
additional charge for any changes requested. ID engraving is personalized to individual
members and cannot be transferred to another individual, altered, sold, or returned. For
full terms, conditions and warranty information please go to www.medicalert.org/warranty.
personal information
select YOUR membership
q Yes q No
previous memberif yes, member number
q
Kid Smart ($40/yr)
q
Advantage ($50/yr)
q
MedicAlert + Safe Return ($55/yr)
First name
Essential ($10/yr) - Available online only
Advance Directive Management Service ($10/yr) - Available online only
Caregiver Membership - Learn more at www.medicalert.org/caregiver
Family Membership - Learn more at www.medicalert.org/family
Middle name
Last name
mailing address
city
select YOUR medical id(s)
unit/Apt #
state
zip
See select medical ID details on back of form or view all medical IDs online
at www.medicalert.org/shopids
ID #
q Work
phone q Home q Cell q Home q Cell q Work
Price
Wrist size (Please measure your wrist & add ½”)
Need measuring tips? Go to www.medicalert.org/sizing
email address (strongly recommended)
date of birth
q Male q Female
gender
$7.00
TOTAL
payment
emergency contacts*
primary emergency contact
emergency contact’s phone
Shipping and handling
relationship
second phone
PRIMARY PHYSICIAN
PHYSICIAN PHONE
MEDICAL CONDITIONS/devices/medications*
q Check q Money Order
q MasterCard® q Visa® q Discover® q AMEX®
No other cards accepted. No CODs. Payment must accompany order.
Credit card number
Expiration date (MM/YY)
credit card holder’s name
credit card holder’s billing address
Signature for card authorization
To ensure uninterrupted MedicAlert membership, your credit card will be
automatically charged the membership renewal rate on your renewal date.
q Check the box if you don’t want us to charge your credit card for renewal.
allergies*
nO KNOWN q MEDICAL CONDITIONS q allergies q medications
* Please attach additional listings if needed
Important: By accepting membership in MedicAlert Foundation, for yourself as member or caregiver
and/or as caregiver on behalf of the member named above (collectively, “you”), you authorize
MedicAlert to release all medical and other confidential information about you in emergencies and
to other health care personnel you designate. If you choose to terminate membership, you must
notify us in writing and return your jewelry. MedicAlert relies upon the accuracy of the information
that you provide. You, therefore, agree to defend, indemnify, and hold MedicAlert (including its
employees, officers, directors, agents, and organizations with which it maintains a marketing alliance
for the provision of services hereunder) harmless from any claim or lawsuit brought by member or
others for injury, death, loss or damages arising in whole or in part out of your provision of incomplete
or inaccurate information to MedicAlert. Furthermore, as caregiver for the member named above,
you hereby represent and warrant to MedicAlert that you have full power and authority, as the duly
authorized representative of such member, to enroll and act on his or her behalf.
Signature of member
Date
(A parent or guardian signature is required for members under the age of 18.)
Prices are subject to change without notice.