Fillable PART 1: TO BE COMPLETED BY CUSTOMER Customer (City of Banning)

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PART 1: TO BE COMPLETED BY CUSTOMER Customer (City of Banning)

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File type: PDF

U.S.A. forms for City of Banning

BROWSE CITY OF BANNING (CA) FORMS

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Revised 10/20/20
PART 1: TO BE COMPLETED BY CUSTOMER
City of Banning Account Number: __ Cycle/Route:___________
Customer Name (as it appears on your
bill
):
Medical Discount resident's name (if
different
):
Service Address
:
Cell Phone: Home
Phone:
I understand that:
1. I must submit a new application with a doctor’s certification every two years. The Electric Utility will mail
me a reminder along with the necessary forms when it is time to reapply. If a resident is visually or otherwise
impaired, I can call the Electric Utility to request special notification of when the mailing is to be sent out for
reapplication.
2. The City of Banning cannot guarantee uninterrupted water and electric service and I am responsible for
making alternate arrangements in the event of an outage or if service
is
interrupted for reasons including but
not limited to non-payment.
I certify under penalty of perjury that the information is true and correct to the best of my knowledge. I also certify
that the Medical Discount resident lives full-time at this address, and requires or continues to require a Medical
Discount. I agree to allow the City of Banning to verify this information. I also agree to promptly notify the City
of Banning if the qualified resident moves or the Medical Discount is no longer needed by the resident.
I understand that if it is discovered that I am receiving benefits without meeting eligibility criteria then I may be
required to reimburse the Electric Utility for up to one year of the benefits incorrectly received.
Customer Signature: ______________________________________ Date: ______________________
The
standard
Medical Discount is $25 per billing cycle.
City of Banning Electric Utility, Public Benefits, 176 E. Lincoln St., Banning, CA 92220 (951) 922-3260
www.banningca.gov
Email us at:PublicBenefits@banningca.gov
MEDICAL DISCOUNT APPLICATION
For Office Use Only
Rate Code:______________ Approved By:______________ Date Approved:_____________ MCM:____ EX:____
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Revised 10/20/20
PART 2: TO BE COMPLETED BY A LICENSED
MEDICAL
DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.)
I certify that the medical condition and needs of my patient are as follows (please print name of patient):
Last Name First Name
1. Requires the use of a life-support device*: Yes _______No _______ (Check One)
If “Yes”, the following life-support device(s) is/are used in the above named patient’s home:
Device(s):
* A qualifying life-support device is any medical device used to sustain life or is relied upon for mobility.
This devise must run on electricity supplied by the City of Banning. It includes, but is not limited to,
respirators (oxygen concentrators), iron lungs, hemodialysis machines, suction machines, electric nerve
stimulators, pressure pads and pumps, aerosol tents, electrostatic and ultrasonic nebulizers, compressors,
IPPB machines, kidney dialysis machines and
motorized wheelchairs. Devices used for therapy rather than
life-support do not qualify.
2. Requires additional cooling and/or heating:
Standard Medical Discounts are available for additional cooling and/or heating if patient is paraplegic,
quadriplegic, and hemiplegic, has multiple sclerosis or scleroderma. Standard Medical Discounts are also
available if patient has compromised immune system or life threatening illness for which additional cooling
or heating is medically necessary to sustain the person's life or prevent deterioration of the person's medical
condition.
Requires Standard Medical Discount for cooling: Yes No (Check One)
Requires Standard Medical Discount for heating: Yes No (Check One)
If “Yes”, please indicate your patient’s medical condition that requires additional cooling or heating:
Medical Condition: _
________________________________________________________________
Doctor’s Name: Phone #:
Office Address:
MD/DO California State License or Military License Number:
SIGNATURE OF DOCTOR: DATE:
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PART 1: TO BE COMPLETED BY CUSTOMER Customer (City of Banning)

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Completed 21 September 2021

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