FORM A-1. SPECIAL NEEDS CUSTOMER MEDICAL CERTIFICATION FORM.

TOWN OF WINNSBORO

SPECIAL NEEDS CUSTOMER MEDICAL CERTIFICATION FORM

   (Please Type or Print All Information)

Customer Information to be completed by customer:

Name                                                                 Account Number                                             

Social Security Number                                                                                                             

Work Phone                          Home Phone                              Cell Phone                                    

Account Address                                                                                    

Patient’s Name                                                                                                                       

Please read the following and initial each one:

_____   I certify that the patient named above is a member of my household residing at the above listed address.

_____   I understand that this Certificate will expire on October 15 and must be resubmitted annually by this date to continue participating in the Special Needs Customer Program.

_____   I further understand that this in no way releases me from my obligation to pay my monthly bill in accordance with the standard payment terms.

Customer’s Signature                                                  Date                                                        

Certificates are not issued for water service that is subject to disconnection.

Medical Information below to be completed by a SC Licensed Healthcare Provider

I certify that I have examined the patient named above and, in my professional opinion as a medical doctor, physician’s assistant, nurse practitioner or advanced-practice registered nurse licensed by the State of South Carolina, I certify it would be especially dangerous to my patient’s health if the electricity and/or natural gas is disconnected for nonpayment of bills for the reason circled below. (The town will attempt to notify these customers of a planned outage whenever reasonably possible.)

 

Nebulizer for asthma, lungs	Feeding (pump) machine	Oxygen machine
Heart monitor	Infant apnea monitor	Ventilator/respirator
Home dialysis treatment	Refrigeration for insulin

 

(CPAP machines for adult sleep apnea do not qualify.)

A detailed explanation for reasons not mentioned above must be submitted for review.

Health Care Provider Name                                       Office Phone                                          

SC Medical License Number                                   

Circle one that applies: Medical Doctor, Physician’s Assistant, Nurse Practitioner, Advanced-Practice Registered Nurse

Office Address                                                                                                                          

Health Care Provider Signature                                                       Date                                     

This form must be faxed (803-635-3697) or e-mailed ([e-mail]) from the office of the SC licensed healthcare provider to the Town of Winnsboro.

Special Needs Customers are in no way released from their obligation to pay their monthly bills according to the terms as noted on the bill.

(Ord. 11-20-06-A, passed 11-20-2006)