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Application for Medical Alert Consideration Status
Date: ___________________________ Account Number: ____________________
Customer’s Name: _______________________________________________________
Customer’s Address: ______________________________________________________
Patient’s Name: __________________________________________________________
Patient’s Telephone Number: _______________________________________________
Provider of Life Support Equipment: _________________________________________
Address: _________________________ Phone Number: ______________________
_________________________
Type of Life Support Equipment: ____________________________________________
Name of Physician: _______________________________________________________
Address: ________________________ Phone Number: ______________________
________________________
Please indicate if prior medical consideration status is no longer needed. Thank you.
_________________________________ Date: ______________________________ Customer’s Signature needed if no longer on medical
**Please attach certified Physicians note as well as Equipment Supplier’s note to Medical Alert Form**
Medical Alert does not relinquish you from paying your account on time, nor does it make you exempt from the delinquency disconnection process. Please make “back-up” arrangements in case of electric outage.
For VMEU/Customer Service use only:
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