N.M. Admin. Code § 17.5.410.43
MEDICAL CERTIFICATION - PLEASE NOTE: To be complete, ALL fields must be filled in, valid, and legible. NOTE: In order to continue to receive gas or electric service from (name of utility), a complete medical certification form and a complete financial certification form must be submitted. This certification is valid for ninety (90) days from the signature date of medical professional.
PATIENT OR LEGAL GUARDIAN
I certify the information provided is true and correct. I understand that if I provide false information, I could be denied continued medical emergency gas or electric utility service from (name of utility company) _____________
I, (printed name of patient) ________________, hereby authorize the medical professional signing this certification to disclose to (name of utility company)_____________the information contained in this medical certification form.
(patient or legal guardian signature) ________________________________ (date) ______________________
PRIMARY UTILITY ACCOUNT HOLDER
I certify the information provided is true and correct. I understand that if I provide false information, I could be denied continued medical emergency gas or electric utility service from (name of utility company)______________
I, (printed name of primary account holder)____________________, hereby certify that I am the person responsible for the charges for gas or electric utility service at (service address) _______________________________ and that a seriously or chronically ill person (as defined by Rule 17.5.410.7 NMAC) resides there.
I further certify that I will immediately notify (name of utility company)___________________ or arrange to have such notification provided, if there is a change in the status of the seriously or chronically ill person residing at the service address, including relocation or a change in the physical condition of such person which renders continued medical emergency gas or electric utility service unnecessary.
(primary account holder signature) _________________________________ (date) ______________________
DOCTOR'S USE ONLY
I, (printed name of medical professional) _________________________________ certify that: I am, (1) a licensed physician or physician's assistant licensed or accepted by the New Mexico medical board and practicing under the New Mexico Medical Practice Act, (2) an osteopathic physician or osteopathic physician's assistant practicing under the New Mexico Osteopathic Physician's Practice Act or (3) a certified nurse practitioner licensed by the New Mexico board of nursing and practicing under the New Mexico Nursing Practice Act; I hold license number/NPI Number_____________; and that on (date)_________ I examined (name of patient) ________________________ who I am informed resides at (service address) ______________________________________________________
I certify that the said person has the following condition in which loss of ____ gas or ____electric (please indicate type of service by checking) utility service would give rise to substantial risk of death or gravely impair health and that this condition qualifies as a serious or chronic illness pursuant to Rule 17.410.7 NMAC:
_____________________________________________________________________________________________
(Describe condition and reasons for continued gas or electric utility service (if applicable, list medically necessary equipment)).
DEFINITION OF SERIOUS OR CHRONICALLY ILL PER RULE 17.5.410.7 NMAC: AN ILLNESS OR INJURY THAT RESULTS IN A MEDICAL PROFESSIONAL'S DETERMINATION THAT THE LOSS OF GAS OR ELECTRIC UTILITY SERVICE WOULD GIVE RISE TO A SUBSTANTIAL RISK OF DEATH OR GRAVELY IMPAIR HEALTH.
(signature of medical professional) ________________ (date) ____________(office address of medical professional) __________________ (telephone number, and fax number of medical professional) _____________________
ONLY for patients meeting the requirements for extended medical certification, also complete the additional certification below if it applies to this patient:
DOCTOR'S USE ONLY - EXTENDED MEDICAL CERTIFICATION (VALID FOR 1 YEAR)
I (printed name of medical professional) ____________certify that the above mentioned patient's medical condition (description of approved condition)_________________is permanent and will not improve within 12 months from ______________ (today's date)
SEE OTHER SIDE FOR FINANCIAL CERTIFICATION
Revised December, 2012
N.M. Admin. Code § 17.5.410.43