Parenting Children With Special Medical Needs: LIPA Medical Emergency Form

I am forwarding a Medical Form from LIPA for persons with special medical needs that require electricity or natural gas for their safety and well-being.

I received this information from Long Island Parent 2 Parent:

When a strong storm rolls through and the power goes out, some families need special attention from LIPA. The Long Island Power Authority has a medical emergency form for families with children with special health care needs. This is the web site address:  http://www.lipower.org/residential/custserv/services.html

Listed below is a note and form to have your doctor fill out. NOTE: this is only for families with children with special medical needs.

To Whom It May Concern:

Please be advised that your patient has stated that a medical emergency exists in their household. As a result, they are required to have their doctor provide the following: • Doctor's note on the doctor's letterhead certifying the medical emergency; and • a fully executed medical emergency form.

**Please note: the following information needs to be provided on your
letterhead when submitting a medical emergency letter on behalf of your patient**

• Current Date

• Doctor's Signature

• Doctor's Name

• Doctor's Address

• Doctor's State Registration #

• Doctor's Telephone #

• Name of the seriously ill person

• Address of the seriously ill person

• Nature of the serious illness or medical condition

• If patient is not the customer of record, relationship to Customer of Record

• Type of Medical Apparatus

• Doctor's Affirmation that the illness will be aggravated by the absence of utility service.

Please complete each item and fax to: (631) 844-3635

Please note, these documents have to be received within five (5) business days or
the customer may be in jeopardy of losing their service.


NOTE: This form must be filled out completely and accompanied by a "letter" submitted on the stationery of your medical doctor or official of the local board of
health qualified to make a medical judgment and shall state the name,
address and state registration number of the certifying medical doctor or qualified health official.

Name on Account:


Account #

Patient Name:

Patient's Home Telephone #

Date of Last Office Visit: _______________________________________

Nature of Illness/Impairment: _______________________________

Type of Medical Equipment Needed: _________________________________

Type of Service Needed for Certification: Electricity____ Gas ____

Is Patient's Condition Dependent on the use of Electricity? Yes ___ No ____

Is Patient's Condition Dependent on the use of Gas? Yes___No ___

(If yes, please explain) ______________________________________________

If yes, please explain) _______________________________________



Is this a First Time Medical Certification? Yes _____ No _____

Is this a Medical Recertification? Yes _____ No _____

Print Doctor's Name: ______________________________________________

Doctor's Signature: ________________________________________

Doctor's Address: ______________________________________________

Telephone # __________________ Fax # _____________________

Doctor's Lic # ______________________________________________

Date: ___________________

The above information is necessary in establishing a short term medical
protection status for your utility services.

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