Oklahoma Human Services' Energy Assistance program uses this two-page form to decide eligibility for life-threatening energy crisis assistance. A licensed health care provider answers yes or no questions on whether the patient needs prescribed equipment that runs on electricity, or refrigerated medication, and whether losing power would be life-threatening.
A licensed health care provider completes the medical equipment, refrigerated medication and additional information sections and signs the attestation with institution name. The client, guardian or parent signs the consent at the top, and the OKDHS worker adds contact information.
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Request for Release of Medical Information (Energy Assistance)
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That the answers are an accurate description of the patient's medical circumstances. The questions ask whether the patient needs prescribed equipment that requires electricity or a refrigerated prescribed medication, and whether being without it during a power outage would be life-threatening.
No. It asks yes or no questions about a condition requiring prescribed equipment or medication, electricity and battery backup, refrigeration and life-threatening risk. An additional information box lets the provider add anything else relevant to the energy crisis request.
Yes. Oklahoma Human Services posts 08AD065S, the Spanish version of the Request for Release of Medical Information, with the same March 2026 date as the English 08AD065E. Both versions include the client consent, the equipment and refrigerated medication questions, and the provider attestation.