Critical Care and Chronic Condition Application

A critical care or chronic condition customer is one which relies on life-sustaining electrically powered medical equipment. In order to be eligible for the program, an application with the following information must be completed. Our Residential Critical Care and Chronic Condition Program does not guarantee priority electric service or priority service restoration, and locations registered in the program are not exempt from planned service interruptions. Whenever necessary, arrangements should be made to move the patient to an alternate location that has power and/or to have backup power available for operation of any electrically operated equipment. Registered customers are not exempt from their financial responsibilities to pay timely for electric utility services provided or from potential termination of service in accordance with City of Burnet policies.

Submission of this application does not automatically result in enrollment. Notification of action taken with regard to this form will be provided to the customer at the mailing address provided. This qualification requires renewal two years from the date you qualified. Patient, or patient's guardian, consents and understands the information on this form may be subject to verification and additional information may be required from you or your physician.

IMPORTANT INFORMATION:

This application must be completed to obtain Chronic or Critical Care designation.
This application will not be processed if incomplete, unreadable, or improperly submitted.
All information is required, unless otherwise indicated.
Submission of this application does not automatically result in Critical Care or Chronic designation.
Customer will be notified upon approval and when the designation is due for renewal.
Pursuant to the Tariff and Business Rules of the City, designation as a Chronic or Critical Care residential customer does not relieve a customer of the obligation to pay for utility services, and service may be disconnected for failure to pay.
Chronic or Critical Care designation does not guarantee continuous electric power.
If electricity is necessary to sustain life, you must make other arrangements for on-site back-up capabilities or other alternatives in the event of power loss.
It is important that we have the most current phone number and mailing address on record.

INSTRUCTIONS FOR CRITICAL CARE or CHRONIC CONDITIONS PROGRAM APPLICATION:

APPLICANT: Complete Part 1 of application and provide to patient's physician to complete PHYSICIAN: Complete Part 2 of application
APPLICANT: Return signed application to the City of Burnet Utility office or via email, fax or mail

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

Customer Information

Account Holder Name (First MI Last) *

Account Number *

Patient Name *

(Name of patient living permanently at the service location who requires chronic condition or critical designation. The patient may be the same person as the customer.)

Service Address *

City/State *

Zip *

Mailing Address (if different)

Primary Phone *

Alternate Phone (if any)

Email Address *

Emergency Contact Information

Emergency Contact Name *

Your application will be rejected unless you include an Emergency Contact Name or insert "I choose not to provide an Emergency Contact name." Failure to include an Emergency Contact may result in disconnecting your electric service without notice if the City of Burnet is unable to contact you.

Emergency Contact Mailing Address

Emergency Contact Phone *

Emergency Contact Alternate Phone

Emergency Contact Email Address *

Physician's Form *

An official document on letterhead from the patient's healthcare official must be submitted along with the application.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

APPLICANT *

I have read and understood the City of Burnet's information on the Residential Critical Care and Chronic Condition Form and certify that the information provided on the application is correct. I understand the information may also be used to determine whether I am eligible for additional notices relating to my electric service. I agree to be contacted by telephone at the phone numbers listed above with respect to the Program. The City is not liable for delayed or undelivered notifications.

APPLICANT SIGNATURE *

DATE OF SIGNATURE

edit-submitted-date-of-signature-month

edit-submitted-date-of-signature-day

edit-submitted-date-of-signature-year

PATIENT/PATIENT'S GUARDIAN, PARENT OR MANAGING CONSERVATOR

I have read and understood the information on the Critical Care and Chronic Condition Form and certify that the information provided in this application about me (or the patient) is correct. I agree to the release of the information on this form concerning my (or the patient's) medical condition for the purposes stated on this application.

PATIENT/PATIENT'S GUARDIAN SIGNATURE

PATIENT/PATIENT'S GUARDIAN DATE OF SIGNATURE

edit-submitted-patient-guardian-date-of-signature-month

edit-submitted-patient-guardian-date-of-signature-day

edit-submitted-patient-guardian-date-of-signature-year

Supporting Documents

Critical Care and Chronic Condition Application (426 KB)