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Get Tx Medical Verification Form - Lubbock City

PRINTMEDICAL VERIFICATION FORMACCOUNT NUMBER:(14digit Number from City of Lubbock Utilities bill)ACCOUNT NAME:SERVICE ADDRESS:DAYTIME PHONE:StreetCityStateZip(Area code) xxxxxxI certify that the termination of electric service would disrupt the use of life support equipment and would createa medical emergency forDOBPatient Namewho is a permanent (mm/dd/yyyy)resident at the above address.Type of equipment utilized:Number of hours in use per day:Physician Name:Physician Phone Number:P.

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