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:

 


 Approved ____        Effective:  _______________


 Denied     ____                                   Month/Year