Part A: CUSTOMER APPLICATION
To the best of my knowledge and belief, the Patient identified above is medically dependent on electric-powered equipment that must be operated continuously or as circumstances require as specified by the Patient’s physician to avoid the loss of life or immediate hospitalization. The Patient is a permanent resident at the Service Address identified above. I agree to notify UCNSB when this equipment is no longer in use. UCNSB has fully explained how my account will be handled regarding any collection action due to non-payment of the bill. I understand that UCNSB does not guarantee uninterrupted service or assign a priority status to my account for service restoration during outages. I understand that I must be prepared with backup medical equipment and/or power and a planned course of action in the event of prolonged outages. I understand recertification of this status is required every 12 months. I agree that UCNSB, upon request of federal, state or local government authorities whose duties or functions include emergency response or disaster relief or prevention, or private entities authorized by congressional charger to assist in disaster relief efforts, may disclose to such requesting entity the following MEES information: The MEES Customer name and service address.
WARNING – PART A – CUSTOMER APPLICATION: Knowingly making a false or misleading statement in completing the Customer Application could result in the denial or termination of the medically essential service application.
Part B: PHYSICIAN’S CERTIFICATE
Upload the Part B: PHYSICIAN’S CERTIFICATE, signed by your physician here.
This form can then be scanned and saved, and uploaded here, or can be printed and mailed to: UCNSB, Attention: Gail Carver, Electric Department, P.O. Box 100 New Smyrna Beach, FL 32170.