Shiner, TX · Lavaca County
Application for Chronic Condition or Critical Care Residential Customer Status
Residential electric customers use this application to request chronic condition or critical care status for a patient living at their service address.
What this form is
This application requests chronic condition or critical care status from the customer’s electric utility. The customer completes page 2, then gives the application to the patient’s physician; the physician completes page 3 and sends the signed application to the applicable transmission and distribution utility. It asks for customer, patient, service address, account, emergency contact, and physician and medical condition information.
Who needs it
An electric customer seeking chronic condition or critical care status for a patient permanently living at the service address should complete the application with the patient’s physician.
How to submit it
The physician must fax or email the completed and signed application to the customer’s applicable transmission and distribution utility, using the contact details listed on page 1.
About notarization
This document is signed without a notary; the customer, patient or guardian, and physician sign and date it, and no notarized or sworn attachment is stated.
How to submit this form
- 1
Download The Application
Download the application PDF.
- 2
Complete Page 2
The customer fills in the required customer, patient, service, account, and emergency contact information and signs and dates the page.
- 3
Have The Physician Complete Page 3
Give the application to the patient’s physician to complete the medical information and sign and date it.
- 4
Send The Application To The Utility
The physician faxes or emails the completed and signed application to the customer’s applicable utility using the page 1 contact details.
Frequently asked questions
- Do I need a notary for the critical care status application?
- No. The customer, patient or guardian, and physician sign and date the application; it does not state that a notarized or sworn attachment is required.
- How do I submit the critical care status application?
- The physician completes page 3 and faxes or emails the signed application to the customer’s applicable transmission and distribution utility, using the contact information on page 1.
- Who completes the application?
- The customer completes page 2 and provides it to the patient’s physician. The physician completes page 3 and sends the signed application to the applicable utility.
- What information does the application request?
- It requests customer and patient details, service and mailing addresses, electric account information, an emergency contact, and physician information about the patient’s medical condition.