Atlantic City Electric customers in New Jersey who rely on electric life-sustaining equipment use this one-page certification. The attending medical professional, who should have examined the patient within the last three months, describes the equipment, its use, backup power and whether an outage would create an immediate life-threatening emergency. If approved, the certification protects service from disconnection for 90 days and enrolls the customer in outage notifications.
The customer completes sections 1 and 2: customer and patient details, including the patient's date of birth and Social Security number. The attending medical professional completes section 3 (name, specialty, office contacts, state license, last exam date) and section 4 (equipment questions), then signs and dates.
Download the current version from the source each time; forms change without notice.
Life Sustaining Equipment Certification
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form asks for the last examination date and notes it should be within three months. The medical professional signing should be the patient's attending professional, who also gives their practice or specialty, office address, phone, email and state license number.
If approved, it is effective for 90 days from the approval date. The program also places the customer in Atlantic City Electric's outage notification process, while the separate Medical Notification Program enrollment form is renewed by the customer each year.