Medical Necessity Form

Member Information

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.

Service Location

Mailing Address

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.

  • 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.