Medical Necessity

To qualify for the “Registration For Medical Necessity” service, the customer must be one who is sixty (60) years old or above or has a condition which hinders the customer from leaving the premises without assistance. The customer is also required to file with the utility, a form approved by the Board of Public Works attesting to the fact that the customer meets the qualifications hereto and signed by a medical physician or authorized agency. This form also must list an agency or an individual other than the customer that the Board of Public Works may contact.

By registering, the Board of Public Works will make an earnest attempt to notify the contact person regarding the status of their utility account. Registering the customer does not guarantee that the utility service cannot be disconnected, but enable us to contact another individual for emergency purposes only.
Today's Date
MM slash DD slash YYYY
Customer Name*
Service Address*
Street Address Address Line 2 City State ZIP Code
Customer Telephone Number*
Contact Person's Name*
Contact Person's Address*
Street Address Address Line 2 City State ZIP Code
Relationship*
Contacts Telephone Number*
Additional Comments
Medical Physician's Full Name*
Physician's Health Care Institution Name*
Medical Physician Signature*
CAPTCHA