N.M. Admin. Code § 17.5.410.44
FINANCIAL CERTIFICATION (VALID FOR 90 DAYS ONLY)
PLEASE NOTE: to be complete, ALL fields must be filled in, valid and legible.
BY SIGNING BELOW, I, THE ACCOUNT HOLDER, ACKNOWLEDGE THAT THIS CERTIFICATE DOES NOT RELIEVE ME OF MY RESPONSIBILITY TO PAY MY CURRENT AND PAST BILLS WITH (NAME OF UTILITY).
* For administering authority (human services department (HSD) or tribal authority) certification: primary account holder completes Section I, and HSD or tribal authority completes Section II.
OR
* For self certification: primary account holder completes Section III and attaches a copy of the primary account holder's current medicaid eligibility.
(Even when extended medical certification is authorized, financial recertification is required every 90 days for the account holder.)
SECTION I - AUTHORIZATION TO RELEASE INFORMATION - PRIMARY ACCOUNT HOLDER
I, (printed name of primary account holder)_________, authorize administering authority to release to (name of utility) information from my file as deemed necessary for the purpose of qualifying for the medical certification program.
I certify the information provided is true and correct. I understand that if I provide false information, I can be denied continued medical emergency gas or electric utility service.
(primary account holder's signature)__________________________(utility account number)__________________
(primary account holder's social security number) ________________(primary account holder's telephone number) ___________________ (service address, city, state, zip code) ___________________________________________
SECTION II - ADMINISTERING AUTHORITY (HSD OR TRIBAL) USE ONLY
I, (name of agency representative)____________________, an authorized representative of (administering authority)__________________ hereby certify that (primary account holder and social security number) ________________________, the primary account holder named in Section I, currently meets the income guidelines as defined by the administering authority (such as low income home energy assistance program (LIHEAP) (agency representative signature)____________________ (phone number and fax number) ______________________ (date)______________
-OR-
SECTION III - SELF CERTIFICATION - PRIMARY ACCOUNT HOLDER - ATTACH COPY OF CURRENT NEW MEXICO MEDICAID ELIGIBILITY FOR PRIMARY ACCOUNT HOLDER
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) (patient's name)___________________ resides there.
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.
(primary account holder signature) ______________ (date) _________ (primary account holder's social security number) _____________________ (service address, city, state, zip code)_________________________________
It is in the account holder's best interest to make regular payments toward current and past due balances; the account holder is encouraged to contact (name of utility) to make payment arrangements.
SEE OTHER SIDE FOR MEDICAL CERTIFICATION
Revised December 2012
N.M. Admin. Code § 17.5.410.44