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. You Tube Like Us facebook.com/ medicalert You Tube Follow Us twitter.com/ medicalert You Tube Watch Us youtube.com/ medicalertsaveslives 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.
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