Medically Essential Service Application at a glance
What it is: Medically Essential Service: Florida Power & Light Company determines whether a customer is eligible for designation as a Medically Essential Service ("MES").
Who signs: Part A must be completed and signed by the Customer and the Patient or Guardian (if other than the Customer). Part B is to be completed by the Patient's physician. Sign on the Physician Signature line and enter the Date.
A filled-in Medically Essential Service Application example: a customer applies for herself
How to fill out Medically Essential Service Application, box by box
Part A: Customer Application
Under Part A: Customer Application, enter the FPL Account No, Customer Name, Service Address, City, State and Zip.
Enter the Daytime Area Code & Telephone No and/or, the Name of Person Using Equipment and the Patient's Physician.
Customer Signature
The Customer signs to state that the Patient is medically dependent on electric-powered equipment that must be operated continuously or as circumstances require as specified by the Patient's physician to avoid the loss of life or immediate hospitalization, and is a permanent resident at the Service Address.
The Customer agrees to notify FPL when this equipment is no longer in use.
In order to be excluded from the disclosure by FPL of the MES information on this form, the Customer must contact FPL to request a Notice of Exclusion From Disclosure.
Sign on the Customer Signature line and enter the Date.
WARNING - PART A - CUSTOMER APPLICATION: Knowingly making a false or misleading statement in completing the Customer Application could result in the denial or termination of the medically essential service certification.
Patient or Guardian Signature, if other than the Customer
Sign on the Patient's or Guardian's Signature line, if other than the Customer, and enter the Date.
Part B: Physician's Name, License, Address and Telephone
Part B is to be completed by the Patient's physician.
Under Part B: PHYSICIAN'S CERTIFICATE, enter the Physician's Name, Physician's License#, Physician's Address and Physician's Area Code & Telephone No and/or.
All fields included in this certificate are required to be completed to be deemed eligible for review.
Part B: Physician's Certificate
After I, write the Name of physician, duly licensed and authorized to practice medicine in the State of Florida; after hereby certify that, write the Name of Patient; after who resides at, write the Patient's place of residence.
Physician Signature
Sign on the Physician Signature line and enter the Date.
WARNING - PART B - PHYSICIAN'S CERTIFICATE: False certification of medically essential service by a physician is a violation of s. 458.3311(1)(h) or s. 459.015(1)(i), Fla. Stat. and constitutes grounds for discipline, penalties and/or enforcement.
More rules for Medically Essential Service Application
If the certificate is deemed valid, it shall be for a period of twelve (12) months from the date the certificate is accepted by FPL for purposes of determining that a customer qualifies as a Medically Essential Service Customer within the meaning of Section 1.65 of the Company's General Rules and Regulations for Electric Service, or that such designation should be renewed.
If any of the fields are left blank, it will cause a delay in the processing of the Medically Essential Service Program application.
Common questions about Medically Essential Service Application
Where do I file it?
Return the entire form, consisting of both Part A and Part B, directly to FPL, Attn: Medically Essential Service Program CSF/GO, PO Box 029100, Miami, FL 33102-9100.
Sources
[1] Medically Essential Service Application, Florida Power & Light Company (the Official source link on this page).