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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?