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Critical Care Instructions and Form DENTON MUNICIPAL ELECTRIC APPLICATION FOR CHRONIC CONDITION OR CRITICAL CARE RESIDENTIAL CUSTOMER STATUS IMPORTANT INFORMATION • This form will not be processed if incomplete, unreadable, or improperly submitted. • For questions about this form, call the City of Denton Customer Service Department during normal business hours at this phone number: (940) 349-8700. • Submission of this application does not automatically result in chronic condition or critical care status. Notification of the action taken by DME with regard to this form will be provided to the Customer at the mailing address provided on this form. • You are notified that designation as a chronic condition or critical care residential customer does not relieve a Customer of the obligation to pay for electric services, and service may be disconnected for failure to pay. • Chronic condition or critical care residential customer status does not guarantee an uninterrupted, regular, or continuous power supply. If electricity is a necessity, you must make other arrangements for on-site back-up capabilities or other alternatives in the event of loss of electric service. INSTRUCTIONS • Customer: Complete Part 1 of the Application Form, and provide the form to patient’s licensed physician for completion. This application will not be processed unless submitted electronically by the physician to DME at the following e-mail address: customer.service@cityofdenton.com or the following fax number (940) 349-7211. • Physician: After completing Part 2 on the following page, please forward only the Application Form to the e-mail address referenced immediately above. PART 1 – CRITICAL CARE RESIDENTIAL CUSTOMER OR CHRONIC CONDITION RESIDENTIAL CUSTOMER INFORMATION Customer Name: __________________________________________ Account Number: ___________ [Name on Electric Account] Electric Service Address: __________________________________________________________________ [Address shown on electric bill – Street, City, State, ZIP Code] Mailing Address: _________________________________________________________________________ [If different than Service Address] Primary Telephone Number: ___________________________ Emergency Contact Name: _____________________________ Emergency Phone Number: _____________ If you have any means of operating your life-support equipment in case of electric power loss, please explain: _________________________________________________________________________________________ Describe the life-support equipment used by the Patient: _________________________________________________________________________________________ The Customer has read and understands the preceding information shown above on this Application Form and hereby certifies that the information provided in this form is true and correct. I understand the information may also be used to determine whether I am eligible for additional notices and other protections relating to the Patient’s electric service that might be available. I understand that I must notify DME, Customer Service within five (5) days in the event that my designation as a Critical Care Residential Customer or a Chronic Condition Residential Customer is no longer needed, or in the event that the Patient moves away from my address. Customer’s Signature: _________________________________ Date: _____________________ Patient’s Name: _______________________________________ Date: _____________________ (Patient is the person who resides permanently at the above Service Address for whom Critical Care Residential Customer or Chronic Condition Residential Customer status is being sought.) PART 2 – TO BE COMPLETED BY THE PATIENT’S LICENSED PHYSICIAN PHYSICIAN’S VERIFICATION I have examined the Patient and in my opinion it is medically necessary or advisable that the Patient needs life-support equipment in Patient’s place of residence. 1. The Patient is dependent upon an electric-powered medical device to sustain life: YES NO [If the answer to Q. 1 is YES, please skip to Q. 3] 2. The Patient has a serious medical condition that requires an electric-powered medical device or electric heating or cooling to prevent impairment of a major life function through a significant deterioration or exacerbation of the Patient’s medical condition. YES NO 3. The Patient’s medical condition has been diagnosed as a life-long condition. YES NO Physician’s Signature: ___________________________________ License Number ______________ Physician’s Printed Name: ________________________________ Address: ___________________________________________________ Phone: _________________ INSTRUCTIONS Customer: Complete Part 1 of the Application Form, and provide the form to patient’s licensed physician for completion. This application will not be processed unless submitted electronically by the physician to DME at the following e-mail address: customer.service@cityofdenton.com or the following fax number (940) 349-7211. Physician: After completing Part 2 on the following page, please forward only the Application Form to the e-mail address referenced immediately above. Critical Care Residential Customer You have the right to apply for “Critical Care Residential Customer” designation. A Critical Care Residential Customer is a “residential customer who has a person permanently residing in his or her home who has been diagnosed by a physician as being dependent upon an electric- powered medical device to sustain life.” In order to be designated as a “Critical Care Residential Customer,” you must have a licensed physician submit the completed application form to Denton Municipal Electric (“DME”). DME will then determine and will notify you whether you are designated a “Critical Care Residential Customer” or not. If approved, the designation of a “Critical Care Residential Customer” is effective for two years. The designation is renewable upon the applicant again meeting the applicable criteria, and an application form must be submitted again, not later than sixty (60) days before the expiration of the two-year certification period. Chronic Condition Residential Customer You have the right to apply for a “Chronic Condition Residential Customer” designation. A Chronic Care Residential Customer” is a “residential customer who has a person permanently residing in his or her home who has been diagnosed by a physician as having a serious medical condition that requires an electric-powered medical device or requires electric heating or cooling to prevent the impairment of a major life function through a significant deterioration or exacerbation of the person’s medical condition.” In order to be designated as a “Chronic Condition Residential Customer,” you must have a licensed physician submit the completed application form to DME. DME will then determine and will notify you whether you are designated a “Chronic Condition Residential Customer,” or not. If the serious medical condition is diagnosed or is re-diagnosed by a physician as a life-long condition, then the designation is effective under this section for the shorter of one year or until such time as the person with the medical condition no longer resides in the home. Otherwise, the designation of a “Chronic Condition Residential Customer is effective” for ninety (90) days. Notice: Designation or re-designation as a “Critical Care Residential Customer” or a “Chronic Condition Residential Customer” does not relieve you of the obligation to pay DME for utility services rendered. However, a “Critical Care Residential Customer” or a “Chronic Condition Residential Customer” who needs payment assistance should contact DME immediately regarding possible deferred payment options or other assistance that may be offered.