Lockhart, TX · Caldwell County
Application for Chronic Condition or Critical Care Residential Customer Status
Lockhart utility customers use this application to request chronic condition or critical care residential customer status for a patient living at their service address.
What this form is
This application requests chronic condition or critical care residential customer status with Lockhart Utilities. The customer completes page 2, and the patient’s physician completes page 3 and submits both pages to the utility department by fax or email. It asks for customer, patient, service address, contact, and emergency contact information, along with the physician’s medical assessment and license details.
Who needs it
A Lockhart utility customer seeking this status for a patient who lives permanently at the service address should complete the customer section and have the patient’s physician complete the application.
How to submit it
The physician must fax or email only pages 2 and 3 to the Lockhart Utility Department at 512-398-5103 or [email protected].
About notarization
This application is signed and dated without a notary; the customer, patient or guardian, and physician sign their respective sections.
How to submit this form
- 1
Download The Application
Download the Lockhart application for chronic condition or critical care residential customer status.
- 2
Complete The Customer Section
The customer completes page 2 with the required customer, patient, address, and contact information and signs and dates the section.
- 3
Have The Physician Complete Page 3
Provide the application to the patient’s physician to complete and sign page 3.
- 4
Submit Pages 2 And 3
The physician faxes or emails only pages 2 and 3 to the Lockhart Utility Department.
Frequently asked questions
- Who completes the critical care status application?
- The customer completes page 2, and the patient’s physician completes page 3. The physician submits only pages 2 and 3 to the Lockhart Utility Department.
- How do I submit the critical care status application?
- The physician must fax the completed pages to 512-398-5103 or email them to [email protected].
- Do I need a notary for the critical care status application?
- No. This application is signed and dated without a notary; the customer, patient or guardian, and physician sign their respective sections.
- Does submitting the application guarantee critical care status?
- No. The application says submission does not automatically result in status; the customer will be notified of the status granted at the mailing address provided.