Welcome to Fairview Health Services secured LIFELINE APPLICATION form. If you have questions about this form, please contact us at 952-885-6185. To complete this form online, please have the following information available:

  • Applicant's information such as address, phone number and date of birth
  • Applicant's health conditions, including any drug allergies and medical conditions
  • Name and telephone number for up to three emergency responders.
  • Billing name, address, and phone number.
Applicant's Information
*Applicant's Full Name (First/Last)
*Applicant's Full Name (First/Last)
*Date of Birth
Primary Language
Home Telephone Number
Cell Phone Number
*Street Address
*ZIP/Postal Code
Applicant's Personal Health Information
Primary Physician Preferred Hospital
Name (First/Last)
Hospital Name
Please list all Drug Allergies Please list all Medical Conditions/Diseases
Personal Contact Information
Please list name and contact information of up to three responders in the order of preferred contact.
Responder One
Name (First/Last)
Primary Language
Home Phone
Work Phone/Extension
Cell Phone
Other Phone
Relationship to Applicant
If response is required and you are not available, do you want to be notified?         
Does responder have a key?         
Notification Information
Would you like to provide an additional contact to be notified in the event of an incident?
(ie: out of town friend or family member, caregiver, etc.)
Billing Information
Please provide where billing information should be sent.
Service Information
Which service would you like?
  Button can be worn around the neck or wrist and is meant for the home and yard (500 foot range).
  Button must be worn around the neck and is meant for home and yard (500 foot range) – button detects 95% of falls
  Button must be worn around the neck and is meant for your home, yard and away from your home. GPS technology. Button detects 95% of falls.
  Monitored medication dispenser holds up to six doses per day.
Installation Arrangements
Please provide a contact to arrange installation
Installation contact is the same as:

Other Information
Please note any other important information:
Referral Source
Submitted by: