LifeFone EZ Referral

Submit this form to refer your clients and keep them protected and living independently 24/7/365 with LifeFone!

Upon submission, a copy will be sent to the email address you provide below. If you have any questions,
please reach out to Daneille Moody at 1-800-882-2280 x 300 or email us at referrals@lifefone.com.

"*" indicates required fields

Referred by:

Your Name / Title / Organization*

Email*

Phone Number*

Help Button Type:

Check option if you choose At Home Landline or At Home Cellular

Necklace

Wristband

Equipment Recommended:*

At-Home Landline (Not compatible with Magic Jack, Frontier, Uma, Vonage, Xfinity, Heritage & Centurylink)

At Home Cellular

VIP Active (All-in-one lightweight necklace system)

VIPx (All-in-one lightweight mobile necklace system)

VIP Flex (All-in-one lightweight mobile wrist/neck system)

Safe Watch Active (All-in-one mobile watch system)

Optional Fall Detection

Subscriber Information:

Name*

Address*

Phone Number*

Email*

Waiver Type*

Date of Birth*

Medicaid ID*

Emergency Contact:

Name/Relationship*

Phone*

Email*

Important Notes:

Subscriber's preferred language, Ship to Address, and Medical history (as needed)

Need help making a referral?
1-877-330-7556
referrals@lifefone.com

24/7 Assistance from our
u.s. based care agents

Rated a+ by the
Better Business Bureau

Waterproof
Pendant & Wristband

Nationwide
Cellular Coverage

LifeFone is a Medical Alert
Provider you can Trust