MEDICAL ALERT PROGRAM
Medical Certification Form
Customer Information to be Completed by Customer:
Name ______________________________________ Account Number ________________
Work Phone ________________ Home Phone _______________ Cell Phone_____________
Account Address _____________________________________________________________
Patient’s Name ________________________________________
Please read the following and initial each one:
___ I certify that the patient named above is a member of my household residing at the above address.
___ I understand that this Certificate will expire on December 31 and must be resubmitted
annually by this date to continue participating in the Medical Certification Program.
___ I further understand that this in no way releases me from my obligation to pay my monthly bill in
accordance with the Town of Clayton’s standard payment terms.
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Section to be completed by a Licensed Healthcare Provider
I herby certify that my patient, __________________________________________, has a chronic or
critical health issue and should be afforded priority consideration for restoration of electric service in
the event of an outage.
Name of Licensed Healthcare Provider __________________________________________________
Signature _________________________________ Date ___________________________________
U
tilities & Billing/Customer Service
111 E. Second Street, Clayton, NC 27520
P.O. Box 879, Clayton, NC 27528
Phone: 919-553-5002
Fax: 919-553-0719
TOWN OF CLAYTON
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