Who completes the form?

The customer, patient or their legal guardian or power of attorney, and the physician each complete the section assigned to them.

What information does the physician provide?

The physician provides contact and license details, the patient’s diagnosis or serious medical condition, required treatment or equipment, and the expected duration.

Coeburn, VA · Wise County

No notary required

Serious Medical Condition Certification Form

Customers, patients or their representatives, and physicians complete this form to certify a serious medical condition associated with a Coeburn utility account.

What this form is

This form documents a serious medical condition for a customer’s water or electric account. The customer and patient or their legal guardian or power of attorney provide account, contact, and authorization details; a physician provides medical information, required treatment or equipment, and the expected duration of the condition. Each section includes a certification and signature line.

Who needs it

A utility customer, the patient or their legal guardian or power of attorney, and the patient’s physician complete the applicable sections.

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 form does not require a notary; the customer, patient or representative, and physician sign and date their sections.

How to submit this form

1
Download The Form
Download the Serious Medical Condition Certification Form.
2
Complete Customer Details
Enter the utility account and contact information, then sign and date the customer section.
3
Complete Patient And Physician Sections
Have the patient or representative and physician complete and sign their respective sections.
4
Submit To The City
Submit the completed form to the city department named on the form; check the city website for current contact details.

Frequently asked questions

Do I need a notary for the Serious Medical Condition Certification Form?: No. This form does not require a notary; the customer, patient or representative, and physician sign and date their sections.
Who completes the form?: The customer, patient or their legal guardian or power of attorney, and the physician each complete the section assigned to them.
What information does the physician provide?: The physician provides contact and license details, the patient’s diagnosis or serious medical condition, required treatment or equipment, and the expected duration.
How do I submit the form?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Serious Medical Condition Certification Form doesn’t need a notary — but if you have another Coeburn form that does, a commissioned online notary can help.