CRITICAL MEDICAL NEEDS WAIVER

CONFIDENTIAL APPLICATION FOR ASSISTANCE

THE PROGRAM

The Critical Medical Needs Program is in place to help any utility customer and/or household members with an existing serious illness or chronic condition, whose condition would be aggravated by the involuntary disconnection or suspension of utility service.

ELIGIBILITY
To be eligible for the program, person must meet the following qualifications:

Live in the state of Missouri.
Household must have Spire gas, Ameren electric utility that has an outstanding balance and/or an American Water bill that is in behind, in threat of disconnect or disconnected.
Have a critical medical or behavioral condition that would be made worse by being without the utility service in the home.
Completed medical waiver form by a verifiable medical / behavioral health representative.
Person must also agree to complete an intake form by phone after medical waiver is received.

NOTE: THIS MEDICAL WAIVER MUST BE COMPLETED BY A CERTIFYING MEDICAL OR BEHAVIORAL PROFESSIONAL OR THEIR REPRESENTATIVE. THE PROVIDER WILL BE CONTACTED TO VERIFY INFORMATION.

Patient Information:

Patient Name:

Primary Patient Phone Number:

Alternate Patient Phone Number

Address:

City:

State:

Zip Code

Date of Birth:

Patient/Guardian Email (if available)

Guardian Name: (if patient under the age of 18)

Certifying Medical Representative

Name:

Phone Number:

Medical Representative Title:

NPI Number:

Medical/Behavioral Health Practice Address:

City:

State:

Zip Code

Declaration

Certified Medical Representative includes Physicians, physician assistants, osteopaths, nurse practitioners, hospice care professionals, nurses or licensed mental health professionals.

I certify that, in my medical opinion, discontinuance of utility service to the patient specified will aggravate an existing critical medical or behavioral health need of the person named above.

YesNo

I certify that I have communicated with the patient and obtained consent to submit this waiver on their behalf.

YesNo

You will be asked for your electronic signature after clicking submit.