Critical Care and Chronic Condition Application Form

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.
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 electric service, 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.

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Customer Information

Account Number *

Account Holder Name *

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 (Secondary) Contact Information

Emergency (Secondary) 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 disconnection of your electric service without notice if the City of Burnet is unable to contact you.

Mailing Address

Emergency Contact Phone *

Emergency Contact Alternate Phone

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.

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.