Rancho Cucamonga, CA · San Bernardino County
Medical Support Assistance Application
Residential customers apply for a monthly utility discount when a full-time household resident regularly needs essential medical support equipment.
What this form is
Rancho Cucamonga Municipal Utility customers use this application to request a monthly discount when a full-time household resident regularly requires essential medical support equipment. The customer and patient’s doctor complete different sections: the customer provides account and patient information, and the doctor certifies the medical condition and required equipment. RCMU reviews applications for approval and may conduct periodic reviews.
Who needs it
A residential utility customer may apply when a full-time household resident regularly requires qualifying medical equipment powered by RCMU electricity.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This application is signed without a notary; the customer signs a declaration under penalty of perjury, and the physician certifies the medical condition and signs the form.
How to submit this form
- 1
Download The Application
Download the Medical Support Assistance Application.
- 2
Complete Customer And Patient Information
Fill in the customer and patient sections and have the customer and patient sign the application.
- 3
Get The Physician’s Certification
Have a medical doctor or osteopath licensed to practice in California complete and sign the physician’s certification.
- 4
Add A Device List If Needed
If more than four devices are required, attach an additional sheet listing them.
- 5
Submit The Application
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Who can apply for Medical Support Assistance?
- A residential customer can apply when a full-time resident of the household regularly requires essential medical support equipment.
- What information does the application ask for?
- It asks for customer account and patient information, customer and patient signatures, and a physician’s certification of the patient’s condition and required life-support equipment.
- Do I need a notary for the Medical Support Assistance Application?
- No. The customer signs a declaration under penalty of perjury, and the physician certifies and signs the form; neither signature is identified as requiring notarization.
- How do I submit the Medical Support Assistance Application?
- Submit it to the city department named on the form; check the city website for current contact details.