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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.

CERTIFICATION OF MEDICAL EMERGENCY FORM

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:

Address:

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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