Medical Utility Waiver Program Enrollment printable pdf download

Medical Utility Waiver Program Enrollment

Medical Utility Waiver Program

Enrollment Form

Policy Effective Date:

1 March 2013

Today’s Date:

Service Member Name:

Rank:

Current Street Address:

Daytime Telephone Number(s):

E‐Mail Address:

Request Made on Behalf of (family member name):

Relationship:

I am requesting a electricity billing waiver for the following reason(s):

Request must be accompanied by the following documents:

1. Signed Medical Utility Waiver Program Enrollment Form

2. Concurrence from EFMP as documented below. Please contact Ms. Tammye Braddy at 703‐805‐3436 for

assistance in requesting EFMP concurrence.

I understand that if approved, the waiver for my electricity billing will take effect as of the first date of the next billing

cycle and that I am responsible for all electric charges incurred before that date.

______________________________________________________________

________________________

Service Member Signature

Date

EFMP/RCLO/Office Use Only

EFMP Recommendation (please sign below):

Concur

Does Not Concur

Date: _________________

Community Director (CD) Recommendation:

Approved

Not Approved

Date: _________________

RCLO Recommendation:

Approved

Not Approved

Date: _________________

Date of Resolution:

Date of Service Member Notification:

EFMP Signature:

Print Name:

CD Signature:

Print Name:

RCLO Signature:

Print Name:

Medical Utility Waiver Program Enrollment Form_JW_Rev071513

Medical Utility Waiver Program Enrollment

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