N.M. Admin. Code § 17.11.16.33
MEDICAL CERTIFICATION FORM (VALID FOR 30 DAYS)
NOTE: You must complete both parts of this Medical Certification Form and a Financial Certification Form to continue receiving telecommunications service.
I, [insert printed name of residential customer], hereby certify that I am the person responsible for the charges for telecommunications service at [insert service address], that a seriously or chronically ill person, [insert name of seriously or chronically ill person] resides there, and that I am financially unable to pay my bill at this time. I understand that this certification does not relieve me of the responsibility to pay my bill, and that I must reapply for financial certification every 90 days. In addition, I understand that I must make arrangements for a payment plan with [insert name of LEC] in order to continue receiving telecommunications service.
[date] [customer's telephone number] [customer's signature]
I, [insert name of medical professional] certify that I am a licensed physician, physician's assistant, osteopathic physician, osteopathic physician's assistant or certified nurse practitioner who holds license number [insert license number] and that on [insert date] I examined [insert name of seriously or chronically ill person] who I am informed resides at [insert service address]. Said person is seriously or chronically ill with [describe condition]. Discontinuance of telecommunications service to this residence might endanger this person's health or life during the recovery period. This certification is valid for 30 days.
[signature of medical professional] [office address and telephone number of medical professional]
N.M. Admin. Code § 17.11.16.33