Medical Certification Form For Electric Service printable pdf download

Medical Certification Form For Electric Service

MEDICAL CERTIFICATION FORM

Date:____________________

Name of Utility:_____________________________

Account Number:_____________________

RE: _______________________________

____________________________________

(Patient Name)

(Name of Account Holder if different from Patient)

_____________________________________

(Patient’s relationship to the Account Holder)

_______________________________________________

(Patient Address)

_______________________________________________

(Address of Account Holder if Different From Patient)

To Whom it May Concern:

I certify that I have examined the patient named above and, in my professional opinion as a

medical doctor, doctor of osteopathy, or nurse practitioner licensed by the State of Pennsylvania, I

certify that the patient is seriously ill and /or afflicted with a condition which will be aggravated by

cessation of electric service. Therefore, in accordance with state law, kindly protect or restore utility

service at this address from shut off. The patient’s condition is as

follows:_______________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________

The patient requires electric service because:_________________________________________

______________________________________________________________________________

Sincerely,

[signature]

_______________________________________

Print name of certifying physician or nurse practitioner

_______________________________________

Address of certifying physician or nurse practitioner

_____________________

Telephone Number

Medical Certification Form For Electric Service