New Mexico Administrative Code › Title 17 - PUBLIC UTILITIES AND UTILITY SERVICES › Chapter 5 - UTILITY INTERCONNECTIVITY AND COOPERATIVE AGREEMENTS › Part 410 - RESIDENTIAL CUSTOMER SERVICE BY GAS, ELECTRIC AND RURAL ELECTRIC COOPERATIVE UTILITIES › Section 17.5.410.43 - MEDICAL CERTIFICATION FORM

Current through Register Vol. 35, No. 13, July 16, 2024
MEDICAL CERTIFICATION -
PLEASE NOTE: To be
				  complete, ALL fields must be filled in, valid, and legible.
NOTE:
In order to continue to receive gas or electric service from (name of utility),
				  a complete medical certification form and a complete financial certification
				  form must be submitted. This certification is valid for ninety (90) days from
				  the signature date of medical professional.
PATIENT OR LEGAL GUARDIAN
I certify the information provided is true and correct. I
				  understand that if I provide false information, I could be denied continued
				  medical emergency gas or electric utility service from (name of utility
				  company) _____________
I, (printed name of patient) ________________, hereby
				  authorize the medical professional signing this certification to disclose to
				  (name of utility company)_____________the information contained in this medical
				  certification form.
(patient or legal guardian signature)
				  ________________________________ (date) ______________________
PRIMARY UTILITY ACCOUNT HOLDER
I certify the information provided is true and correct. I
				  understand that if I provide false information, I could be denied continued
				  medical emergency gas or electric utility service from (name of utility
				  company)______________
I, (printed name of primary account
				  holder)____________________, hereby certify that I am the person responsible
				  for the charges for gas or electric utility service at (service address)
				  _______________________________ and that a seriously or chronically ill person
				  (as defined by Rule
				  17.5.410.7
				  NMAC) resides there.
I further certify that I will immediately notify (name of
				  utility company)___________________ or arrange to have such notification
				  provided, if there is a change in the status of the seriously or chronically
				  ill person residing at the service address, including relocation or a change in
				  the physical condition of such person which renders continued medical emergency
				  gas or electric utility service unnecessary.
(primary account holder signature)
				  _________________________________ (date) ______________________
DOCTOR'S USE ONLY
I, (printed name of medical professional)
				  _________________________________ certify that: I am, (1) a licensed physician
				  or physician's assistant licensed or accepted by the New Mexico medical board
				  and practicing under the New Mexico Medical Practice Act, (2) an osteopathic
				  physician or osteopathic physician's assistant practicing under the New Mexico
				  Osteopathic Physician's Practice Act or (3) a certified nurse practitioner
				  licensed by the New Mexico board of nursing and practicing under the New Mexico
				  Nursing Practice Act; I hold license number/NPI Number_____________; and that
				  on (date)_________ I examined (name of patient) ________________________ who I
				  am informed resides at (service address)
				  ______________________________________________________
I certify that the said person has the following condition in
				  which loss of ____ gas or ____electric (please indicate type of service by
				  checking) utility service would give rise to substantial risk of death or
				  gravely impair health and that this condition qualifies as a serious or chronic
				  illness pursuant to Rule 17.410.7 NMAC:
_____________________________________________________________________________________________
(Describe condition and reasons for continued gas or electric
				  utility service (if applicable, list medically necessary equipment)).
DEFINITION OF SERIOUS OR CHRONICALLY ILL PER RULE
				  17.5.410.7
				  NMAC:
AN ILLNESS OR INJURY THAT RESULTS IN A MEDICAL PROFESSIONAL'S
				  DETERMINATION THAT THE LOSS OF GAS OR ELECTRIC UTILITY SERVICE WOULD GIVE RISE
				  TO A SUBSTANTIAL RISK OF DEATH OR GRAVELY IMPAIR HEALTH.
(signature of medical professional) ________________ (date)
				  ____________(office address of medical professional) __________________
				  (telephone number, and fax number of medical professional)
				  _____________________
ONLY
for patients meeting the requirements for
				  extended medical certification, also complete the additional certification
				  below if it applies to this patient:
DOCTOR'S USE ONLY - EXTENDED MEDICAL CERTIFICATION
				  (VALID FOR 1 YEAR)
I (printed name of medical professional) ____________certify
				  that the above mentioned patient's medical condition (description of approved
				  condition)_________________is permanent and will not improve within 12 months
				  from ______________ (today's date)
SEE OTHER SIDE FOR FINANCIAL
				  CERTIFICATION
Revised December, 2012