Get Policy Cs-0004a Certificate Of Medical Emergency Form

Completing the Policy CS-0004A Certificate Of Medical Emergency Form is essential for ensuring that individuals with medical conditions receive the necessary support. This guide will walk you through the process of filling out the form online with clear and detailed instructions.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the customer's name in the designated field at the top of the form. Ensure that all names are spelled correctly to avoid any delays in processing.
3. Enter the account number associated with the service. This information is crucial for identification and processing.
4. Provide the service address where utilities are supplied. This should include the complete address, including city, state, and zip code.
5. Identify the person in the household who has a medical condition. Enter their name clearly, as this will be referenced in the physician's statement.
6. In the next field, indicate the relationship of the person with the medical condition to the customer. This helps establish the context of the medical emergency.
7. The next section includes a statement from the licensed physician. Ensure that the physician’s statement includes the name of the individual under care and their medical condition, as well as the potential consequences of utility service discontinuance.
8. The physician must sign and print their name in the designated areas. It is essential that the physician’s signature is included, as it validates the statement.
9. Complete the date field with the date the statement is being signed by the physician.
10. Finally, include the physician's phone number so that utilities can contact them if necessary.
11. Review all filled-in sections for accuracy. Once confirmed, save your changes, then download, print, or share the completed form as required.

Complete your Policy CS-0004A Certificate Of Medical Emergency Form online today!