Residential critical care program application
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- CPS ENERGY RESIDENTIAL CRITICAL CARE PROGRAM APPLICATION
- If the Applicant meets the above stated conditions, Customer shall complete Part A. Part B must be completed by a physician and submitted from the physician’s office. Other
- Customer Obligations
- Part A: Account Holder Information (Please print)
- Physician Certification
- This application is required to be faxed by the Physician office to CPS Energy at (210) 353-3666.
 
CPS ENERGY RESIDENTIAL CRITICAL CARE PROGRAM APPLICATION CPS Energy’s Critical Care program provides qualified customers additional time to pay their bills if they, or a dependant living in their home, must use electrically-operated medical equipment in their home. In order to be eligible, the following conditions must be met:
If the Applicant meets the above stated conditions, Customer shall complete Part A. Part B must be completed by a physician and submitted from the physician’s office. Other Program provisions:
Customer Obligations:
Contract Account #:_______________________ Customer Name: ____________________________________________ Telephone #: ____________________ Address: ________________________________________ City/St: _____________________________ Zip: _______________ Patient’s Relationship to Account Holder: ______________________________________________________________________ Patient currently resides at: _________________________________________________________________________________ _______________________________________________________________________________ Part A: Account Holder Information (Please print) Patient’s Name: ________________________________________________ Date of Birth: ______________________________ Physician’s Name: __________________________________________________ Telephone #: ___________________________ Physician’s Address:_______________________________________________________________________________________
I hereby certify that the Patient who is seeking qualification in CPS Energy’s Critical Care Program requires medical equipment at the address listed in Part A. __________________________________________________ ______________________________________ Physician’s Signature Date
For CPS Energy Representative: (Initial and Date) Received Time: _____:_____ Validated by: __________ SAP Processed ________ Completion Time: ____:_____ Prepared by: Customer Billing Solutions Page 1 of 1 \\cps05782\Billing_&_Accounts_Rec\Customer Outreach May 2012 Directory: content -> dam dam -> Resolution dam -> American bar association adopted by the house of delegates dam -> Chevrolet – the Story of a Global Brand A. Louis Chevrolet and the Legend of Beaune dam -> Embargo until 12/17/12 dam -> October/November 2015 Teacher's Guide Table of Contents dam -> Boston College Athletics Advisory Board Annual Report, 2011-12 dam -> Executive Board of the United Nations Development Programme, the United Nations Population Fund and the United Nations Office for Project Services dam -> Boston College Athletics Advisory Board Annual Report, 2010-11 Download 12.18 Kb. Share with your friends:
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