Svec Medical Necessity Form


Medical Necessity Form
Account Information:
Account #:_____________________
Name on Account: ___________________________________________________
Service Location Address: _____________________________________________
Home Phone: ___________________
Mobile Phone: __________________
Name of Person Using Equipment: ____________________________________
Medical Equipment:
Type of Equipment in Use: ___________________________________________
Is this equipment necessary to sustain life:
□ Yes
□ No
Physician’s Certification:
Physician’s Name (please print):_______________________________________
Address: __________________________________________________________
Phone Number: _______________________
As the above patient’s physician, I certify that the above listed equipment is necessary to sustain
life for my patient.
Physician’s Signature_________________________________ Date: ___________
The information collected above will be used in the event of prearranged power outages and
disconnects. This form does not guarantee a higher level of service or guaranteed service should
the area experience a power outage.
This form is for information purposes only and is valid for one year. An updated form is required
each year.
SVEC Internal Use Only
Date Received: ___________ By: ________________________


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Parent category: Medical