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 and/or Ameren electric utility service disconnect notice or already turned off
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 representative
Person must also agree to complete an intake form by phone after medical waiver is received

NOTE: This medical waiver form MUST be completed by a certifying medical professional.

Patient Information:

Patient Name:

Phone Number:

Address:

City:

State:

Zip Code

Date of Birth:

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

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