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Here's your application for a Medical Lifeline Allowance If you or someone who lives in your home uses life-support equipment, you may be eligible to pay a lower rate for some of your electricity. This is called our medical lifeline allowance. MAIL COMPLETED APPLICATION TO: ANAHEIM PUBLIC UTILITIES DEPARTMENT CUSTOMER SERVICE P.O. BOX 3222 ANAHEIM, CALIFORNIA 92803 ---PAGE BREAK--- How do I know if I qualify? You may qualify if you or someone who lives in your home • is a paraplegic, hemiplegic, quadriplegic, a multiple sclerosis, or scleroderma patient. • uses medical life-support equipment in your home to sustain life. Life-support equipment is any electrically operated device that mechanically or artificially sustains life or restores or replaces a vital function. It can also be mechanical equipment that someone needs to move around inside and outside of buildings. What medical equipment qualifies? You may apply for a medical lifeline allowance if you use one of these: • aerosol tent • apnea monitor • compressor/concentrator • electric nerve stimulator • electrostatic nebulizer • hemodialysis machine • inhalation pulmonary pressure breather (IPPB) machine • iron lung • motorized wheelchair • oxygen generator • pressure pad • pressure pump • respirator (all types) • suction machine • ultrasonic nebulizer • air conditioning Other life-support equipment that is operated by electricity may qualify, but we will make that decision on an individual basis. If your life-support equipment is not on this list and you believe that you should qualify, please write the name of the equipment on the application. Our lifeline specialist will decide if you qualify for the allocation. What medical equipment does not qualify? We do not authorize life-support equipment • for which we do not supply the electricity or • that you or someone who lives in your home uses for therapeutic purposes, such as whirlpool pumps, heating pads, vaporizers, humidifiers, pool or tank heaters, or hot tubs. What happens if the power goes out? Power outages may be caused by circumstances that are beyond our control. For example, a windstorm could cause a temporary power outage. For this reason, patients should consider providing and maintaining a back-up power system. What if I live in a duplex, apartment, or mobile home park and my landlord pays for electricity? If you live in • a duplex, apartment building, or mobile home park, and • we supply your electricity through a master meter to your apartment building or mobile home park, you may apply for this allocation. We will include the allocation in the electric bill to your landlord. For more information please call our lifeline specialist. How do I apply? Fill in the form. Notice that one part is for you and one part is for the doctor or osteopath. After we receive your form, we will determine if you qualify for the allocation. We may need to visit your home to verify the type and size of your equipment. After you and the doctor or osteopath fill in the form, mail it to: Anaheim Public Utilities Department Customer Service P.O. Box 3222 Anaheim, California 92803 If we approve your application, your allocation will become effective with your next bill. What if I move to another location in Anaheim? If you move and the life-support equipment will be used in your new home, notify our lifeline specialist. We will send a new application to you. Do I have to renew my application? Yes, we review your file every one to two years. The type of illness the person has and the type of life-support equipment used determines when we review your file. We may ask that you have the doctor send a new application to verify that you still need the equipment in your home. If you change your life-support equipment or the way in which you use the equipment, please contact our lifeline specialist; you may need to complete a new application. KEEP THIS PART PUI PUD-156 REV 10/04 ---PAGE BREAK--- To apply for the medical lifeline allowance, please print: Customer’s full name Patient’s full name Patient’s Social Security Number Patient’s Drivers License Number Patient’s relationship to customer Patient’s address City State Zip Daytime telephone number Emergency Telephone Number Do you have a back-up power system? Yes How many hours will it last? hours No AGREEMENT I, THE UNDERSIGNED, as a customer of the Anaheim Public Utilities Department (Anaheim), hereby claim eligibility and make application for the electric rate discount for Life Support Device for home usage. The device described is used in my home and is an essential life support unit powered by Anaheim. I hereby grant right of access to my residence during regular business hours to Anaheim for verification of information given on this application if necessary. I understand that refusal of access for this purpose will be considered just cause for denial of rate discounts. I agree to notify Anaheim immediately if use of apparatus is changed. A new application and/or doctor’s certification for this rate will be subject to approval by Anaheim and will be subject to bi-annual renewal and approval. All information given on this application is true to the best of my knowledge. I understand that any misinformation could lead to disqualification for the Life Support rate discount. Do you or someone who lives in your home use an apnea monitor? Yes No Does your medical condition require that you use air conditioning? Yes No Total square footage of your dwelling? ft. What life support equipment do you have? ANAHEIM PUBLIC UTILITIES USE ONLY Account Number Review Date Approved / Denied by Medical Lifeline Allowance kWh per month seasonal kWh from May to Nov Master Metered Account: Owner’s Name Phone # Address Unit # Add Remove Update Cust Master Special Code (M/L) Misc Note Last Read Rate Change / Prior DS/DD OVERRIDE DL Location Surcharge General Location LSP – Work Request LSP – Letter – Operations Cust Ltr / Spreadsheet Certified Ltr / LSP Spreadsheet Signature of Applicant Date Patient must complete this page ---PAGE BREAK--- PHYSICIAN'S VERIFICATION I hereby certify that (FIRST NAME) (INITIAL) (LAST NAME) is a: paraplegic (paralysis of lower half of the body with involvement of both legs) quadriplegic (paralysis of both arms and both legs) hemiplegic (paralysis of one lateral half of the body) has: scleroderma multiple sclerosis other (specify) DOCTOR'S NAME CA LICENSE NUMBER ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER SIGNATURE OF DOCTOR DATE Area Code ( ) What life-support equipment does your patient need to use regularly? aerosol tent iron lung During a service interruption, apnea monitor motorized wheelchair can your patient survive without compressor/concentrator oxygen generator using the life-support equipment electric nerve stimulator pressure pad that you describe? electrostatic nebulizer pressure pump yes no hemodialysis machine respirator (all types) How long? inhalation pulmonary pressure suction machine 1 hour breather (IPPB) machine ultrasonic nebulizer 2 hours other (give name of equipment air conditioning required 4 hours and explain why it should qualify) 8 hours 12 hours 24 hours or more life support therapeutic Length of time (in months) patient needs to use this equipment Equipment is Physician must complete this page