Svec Medical Necessity Form printable pdf download

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: ________________________

Svec Medical Necessity Form