Fillable LIFE SUPPORT APPARATUS CERTIFICATION (Central Hudson)

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LIFE SUPPORT APPARATUS CERTIFICATION (Central Hudson)

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  • 14 check-boxes
  • 25 other fields

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www.CentralHudson.com · 284 South Avenue, Poughkeepsie, NY 12601
LIFE SUPPORT APPARATUS
CERTIFICATION
Please print or type LSA No.
SECTION I - Individual Using Medical Equipment
Name of person using life support device: Age:
Address: Telephone No:
Person to contact in case of emergency: Telephone No:
SECTION II - Customer Information & Statement
Is your residence located in:
Private Home – Homeowner’s Name:
Complex/Facility – Name:
Central Hudson Customer Name: Account No.:
I, the undersigned, understand that while on the Life Support Program, I remain solely responsible for
payment of utility service and shall make reasonable efforts to pay charges for such service.
Customer Signature: Date:
SECTION III - Medical Equipment Information
Tank-Type Respirator (Iron Lung) Rocking Bed
Cuirass-Type (Chest) Respirator Suction Machine (Pump)
Electrically Operated Respirator Hemodialysis Equipment (Kidney Machine)
(Operated 12+ hours per day)
Intermittent Positive Pressure Respirator
APNEA Monitor (Infants Only) Continuous Ambulatory Peritoneal Dialysis
Other Type of Life Support Device
(please describe)
Frequency of Use: Times Per Week: Hours Per Day:
Name of Equipment Supplier: Telephone No:
Does customer have back-up equipment in case of power outage? Yes No
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www.CentralHudson.com · 284 South Avenue, Poughkeepsie, NY 12601
LIFE SUPPORT APPARATUS
CERTIFICATION
SECTION IV - Physician’s Statement
In accordance with the definition of a life support device and the information listed above as proof of
use of such a device, I certify that the above-named individual does require an electrically operated
device to sustain his/her life. This equipment requires uninterrupted electrical power for extended
periods of time.
Physician: Physician’s License Number:
Telephone No.:
Address:
Signature: Date:
SECTION V - To Be Completed If Equipment Is No Longer Required
I hereby certify that life support equipment is no longer in use and the protection afforded by Central
Hudson’s Life Support Program are no longer required.
Name:
Signature: Date:
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LIFE SUPPORT APPARATUS CERTIFICATION (Central Hudson)

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Completed 9 June 2021

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