†††††††††††††††† Application for Medical Alert Consideration Status

 

 

 

 

Date:† ___________________________†††††††† Account Number:† ____________________

 

Customerís Name:† _______________________________________________________

 

Customerís Address:† ______________________________________________________

 

Patientís Name:† __________________________________________________________

 

Patientís 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:† ______________________________

Customerís Signature needed if no longer on medical

 

**Please attach certified Physicians note as well as

Equipment Supplierís 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 ďback-upĒ arrangements in case of electric outage.††

 

For VMEU/Customer Service use only:

 


†Approved ____††††††† Effective:† _______________


†Denied†††† ____†††††††† †††††††††††† †††††††††††† Month/Year

†††††††††††† †††††††††††† ††††††††††††

†††††††††††† †††††††††††† †††††††††††† †††††††††††† ††††††††††††