Medical Necessity Form
Member Information
PEC Member First Name
PEC Member Last Name
Patient First and Last Name
Name of Patient living permanently at the Service Location who requires chronic condition or critical designation pursuant to
PEC’s Tariff and Business Rules
. The Patient may be the same person as the Member.
Enter your Account # on Your PEC Bill
Is a generator installed at your location?
Yes
No
I Don't Know
Member Primary Phone
Alternate Phone
Application ID
Billing Account Lookup
Salesforce Account
Salesforce Contact
Record Type ID
Service Location
Street
City
State
Zip Code
Is the Mailing Address different than the Service Location?
Yes
No
Mailing Address
Street
City
State
Zip Code
Service Location
Emergency (Secondary) Contact Information
Your application will be rejected unless you include an Emergency Contact name or insert “I choose not to provide an Emergency Contact name.” Failure to include an Emergency Contact may result in disconnection of your electric service without notice if PEC is unable to contact you.
Emergency Contact Name:
Mailing Address Street
City
State
Zip
Emergency Contact Primary Phone
Emergency Contact Alternate Phone
Consent
IMPORTANT INFORMATION:
This application must be completed to obtain Chronic or Critical
Care designation with Pedernales Electric Cooperative, Inc.
This application will not be processed if incomplete. All information is required, unless otherwise indicated.
Submission of this application does not automatically result in Chronic or Critical Care designation. Members will be notified upon approval and when the designation is due for renewal.
Pursuant to the Tariff and Business Rules of PEC, designation as a Chronic or Critical Care residential member does not relieve a member of the obligation to pay for electric service, and service may be disconnected for failure to pay.
Chronic or Critical Care designation does not guarantee continuous
electric power. If electricity is a necessity to sustain life, you must make other arrangements for on site back up capabilities or other alternatives in the event of power loss.
Member Verification:
By clicking the submit button below, I
acknowledge that I have read and understood
PEC’s information on the Medical Necessity
Program and certify that the information
provided on this application is correct. I agree
to be contacted by telephone at the phone
number(s) I’ve provided with respect to the
Medical Necessity Program.
PATIENT/PATIENT'S GUARDIAN, PARENT, OR MANAGING CONSERVATOR:
I have read and understood the information on the Medical Necessity Program and certify that the information provided in this application about me (or the patient) is correct. I agree to the release of the information on this form concerning my (or the patient’s) medical condition for the purposes stated on this application.