SPECIAL NEEDS CUSTOMER
REGISTRATION & CERTIFICATION
SC1108i (12/03/2015) (FS)
Patient Name:
Patient/Guardian
Signature:
Please identify and describe the condition that qualifies the patient for this Special Needs Program:
Based on the patient's illness, please check one of the following options:
To be completed by Account Holder
To be completed by Healthcare Provider
Service Address:
Mailing Address:
(if different)
Phone:License No.:
Signature:
Address:
Account Number:
Home Phone:
Email Addres:
Cell Phone:
Customer Signature:
I agree to the terms of the Special Needs Customer Program.
Describe health condition: Expected duration of condition:
List electric equipment required:
Hours per day used:
Disconnection of electrical service would be extremely hazardous to the health of the patient because electricity
is used to operate equipment that is required for continual life support.
Disconnection of electrical service for more than a few hours may be a health risk for the patient if no alternative
arrangements are made.
Disconnection of electrical service would be an inconvenience to the patient's health but does not represent a life
threating situation.
Is the customer: Ambulatory?
Patient's
Date of Birth:
Today's Date:
Date:
Date:
I,
, (M.D., P.A., N.P., A.P.R.N. - Circle one) am a licensed Healthcare
Provider in the State of . I hereby certify the above to be true and accurate to the best of my knowledge.
Account Name:
Chronically ill On Life Support Other:
Yes No
Yes No
Able to leave home unassisted?
If Yes, how long is it good for:
Would you like to participate in the
Third Party Notification program?
Does the customer have a back up system?
No
YesNo
Yes
Santee Cooper
Special Needs Coordinator
305A Garnder Lacy Road
Myrtle Beach SC 29579-7248
Please return completed form to:
(843) 347-3399
Berkeley County Area: (843) 761-8000
For information
contact:
Horry/Georgetown County Area:
To qualify for the Special Needs Customer Program, you or a member of the same household must be chronically ill and/or
on some sort of life support device. Acceptance into this program will allow Santee Cooper to handle your account with
special care; however, in the event of nonpayment of your bills, your account will be subject to Santee Cooper's
disconnection rules. Special Needs customers will need to recertify medical status every year.
Third Party Notification: This allows a third party to be notified when service is scheduled for disconnection. The
Third Party is not responsible for payment of the customer's bill.
à
Address:
Home Phone: Cell Phone:
Third Party Name:
Signature required; print & sign
