Get Dominion Form Smcc 2017-2025

This guide provides a comprehensive overview of how to fill out the Dominion Form SMCC, which is essential for certifying serious medical conditions. Whether you are familiar with online forms or not, these clear instructions will assist you in navigating the process effectively.

Follow the steps to complete the Dominion Form SMCC online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the customer name and address in the designated fields.
3. Input the electric account number and water account number, ensuring all information is accurate.
4. Provide the customer’s contact telephone number and, if available, an alternate telephone number.
5. Complete the city, state, and zip code fields.
6. As the customer, certify that the information provided is correct and that the patient is either the customer or a family member residing at the specified address by signing and dating the customer signature field.
7. In the section for patient/legal guardian/power of attorney, fill in the patient’s name and state their relationship to the customer.
8. Enter the contact telephone number and any alternate number for the patient.
9. Authorize the release of the patient's medical information by signing in the required field.
10. Next, the physician section must be completed, starting with the physician's name and office address, including city, state, and zip code.
11. Provide the physician's current license number, the patient's diagnosis or serious medical condition, and the contact telephone number along with an alternate and fax number.
12. Check all the prescribed treatments or required equipment related to the patient’s condition from the given options.
13. Indicate the expected duration of the condition in the designated space.
14. Finally, the physician must certify the information provided is accurate by signing and dating the physician’s signature field.
15. Once all sections are filled out, save changes, download, print, or share the completed form as needed.

Complete your Dominion Form SMCC online today for efficient processing.