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.
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 ___________________________________
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
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