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.