Form Smcc – Fill Out and Use This PDF

		Serious Medical Condition Certification Form
Form SMCC (10/2011)
To Be Completed by the Customer:
Customer Name:				Electric Account Number:
Customer Address:				Water Account Number:
				Contact Telephone Number:
City:	State:		Zip 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.

Customer Signature:			Date:
To Be Completed by the Patient/ Legal Guardian/ Power of Attorney:
Patient Name:	Patient 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 if the identified medical condition(s) meets the definition of 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:			Contact Telephone Number:
Physician Office Address:			Alternate Telephone Number:
City:	State:	Zip Code:	Fax Number:
Current License Number:			Licensing State:
Patient's Diagnosis/ Serious Medical Condition:

Equipment prescribed and/or required treatment for condition:

Expected Duration of Condition:

Additional Comments:

I certify that the above patient has a serious medical condition which is defined as a physical or psychiatric condition that requires medical intervention to prevent further disability, 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 condition carries with it a risk to health beyond that experienced by the majority of children and adults in their day-to-day minor illnesses and injuries. 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. Medical interventions may include medications with special storage requirements, use of powered equipment, or access to water. I certify that the preceding information is correct.

Physician's Signature:	Date:

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