Form Of Dominion – Fill Out and Use This PDF

Dear Customer,

If you have a serious medical condition, please print a copy of this form and contact us at 1-866- DOM-HELP (1-866-366-4357) in order to apply a 10-day extension to your active account.

Individuals with a serious medical condition may require administration of specialized treatments and may be dependent on medical technology such as ventilators, dialysis machines, enteral or parenteral nutrition support, or continuous oxygen.

To extend the note, have your doctor complete and return the Serious Medical Condition Certification Form to us within 10 days. We will notify you when the completed form is received and if you are eligible for the medical program. If your medical condition changes, please call us toll-free at 1-866-DOM-HELP (1-866-366-4357).

If severe weather causes extensive damage, restoration of service may take several days. Because we cannot guarantee uninterrupted electrical service, we urge you to have an alternate care plan or maintain a battery-powered backup.

Upon our receipt of your approved Serious Medical Condition Certification Form (Form SMCC (10/2011) within the 10-day time period, you will have the right to delay termination of service for 30 calendar days. You may delay termination twice within a 12-month period, as long as the medical form is active on your account.

To report an outage, please call us toll-free at 1-866-DOM-HELP (1-866-366-4357). To avoid holding on the line for a representative, say “power outage” when the Interactive Voice Response system answers; your outage will be reported to the appropriate local office. To speak with a representative about your outage say, “I’d like to report an issue” when prompted.

A medical note on an account does not release a customer from bill payments, nor does it eliminate the possibility of eventual cut-off for nonpayment. We realize that severe medical conditions can place a strain on your budget. If you experience financial hardship, please call us to work out a payment arrangement.

Sincerely,

Dominion Virginia/North Carolina Power

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Serious Medical Condition Certification Form

Form SMCC (10/2011)

To Be Completed by the Customer:

Customer Name:			Electric Account Number:
Cuslomer Address:			Water Account Number:
			Contact Telephone Number:
City:	lState:	lZip Code:	Alternate Telephone Number:

I certify that the information provided above is accurate and the patient is the customer or a family member of the customer residing at this residence.

Cuslomer Signature:

Date:

To Be Completed by the PatienV Legal Guardian/ Power of Attorney:

Patient Name:	I Ratient Relationship to Customer:
Contact Telephone number:	Alternate Telephone Number:

I hereby authorize my physician to release the following information about the above-named patient to the utility's representatives and/or the State Corporation Commission and to answer related questions to help determine il the identilied medical condition(s) meets the definition ol a serious medical condition which is defined below. I certify that the patient lives at the address listed above and that all information provided is accurate.

Patient/ Legal Guardian/ Power of Attorney Signature:

Date:

To Be Completed by the Physician (M.D. or D.O.):

Physician Name:		Conlact Telephone number:
Physician Olfice Address:		Alternate Telephone Number:
City:	lState: lZip Code:	Fax Number:
Current License Number:		Licensing State:

Patient's Diagnosis/ Serious Medical Condition:

Equipment prescribed and/or required treatment for condition:

Exoected Duration of Condition:

Additional Commenls:

I certify that the above patient has a serious medical condition which is defined as a physical or psychiatric condition that requires medical interuention to prevent further disahility, loss of function, or death. Such conditions are characterized by a need for ongoing medical supervision or the consultation of a physician. A serious medical conditon carries with it a risk to health beyond that experienced by the majoity of children and adults in their day-to-day minor illnesses and injuries. lndividuals with a serious medical condition may require administration of specialized treatments and may be dependent on medical technology such as ventilators, dialysis machines, enteral or parenteral nutrition support, or continuous oxygen. Medical interventions may include medications with special storage requirements, use of powered equipment, or arcess to

water. lcertify that the preceding information is conect.
Physician's Signature:	Date:

This form was developed pursuant to: 20VAC 5-330 "Limitations on Disconnection of Electric and Water Service"

Physician: Pleasemail completedlormlo: DominionCreditServices,POBox26666,Richmond,VA2326.l ORFaxto: 1-888-867-3'133.

lf you have questions about this form, please call: 1-866-DOM-HELP (1-866-366-4357),