Get 18663664357

This guide provides a detailed overview of how to effectively fill out the 18663664357 form online. Whether you are applying for the Serious Medical Condition Certification or assisting someone else, these steps will help make the process straightforward and efficient.

Follow the steps to accurately complete the 18663664357 form online.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in the customer information section, including the customer's name, address, electric and water account numbers, and telephone contact details.
3. Certify that the information provided is accurate and that the patient is either the customer or a family member living at the same residence by signing in the designated customer signature area.
4. For the patient or their legal representative, provide the patient's name, relationship to the customer, and the required contact information.
5. Authorize the physician to release necessary information by signing in the patient/legal guardian/power of attorney signature area.
6. The physician must then complete their section, which includes their name, office address, license number, and the patient’s diagnosis. They need to list any required treatments or prescribed equipment.
7. Physicians must certify the patient's serious medical condition in their section by signing and dating the form.
8. Once all sections are completed, review the document for accuracy, and make any necessary edits.
9. Save changes to the form, and then proceed to download, print, or share the completed document as needed.

Complete your serious medical condition certification form online today.