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UPPER
CUMBERLAND ELECTRIC MEMBERSHIP CORPORATION PATIENT’S NAME ____________________________________________________ ADDRESS __________________________________________ZIP ______________ PHONE NUMBER WHERE PATIENT LIVES______________________________ TYPE ILLNESS _______________________________________________________ PATIENT’S DOCTOR _________________________________________________ DOCTOR’S ADDRESS ________________________________________________ DOCTOR’S PHONE ___________________________________________________ TYPE OF MEDICAL EQUIPMENT ______________________________________ NAME OF COMPANY SUPPLYING EQUIPMENT _________________________ ADDRESS ______________________________________PHONE _____________ PERSON TO CONTACT AT MEDICAL SUPPLY CO ______________________ VOLTAGE RATING OF EQUIPMENT IN SERVICE_______________________ TIME EQUIPMENT USED_________ HOURS ________DAYS ________WEEKS HOW MUCH RESERVE TIME FOR EMERGENCY, IF ANY ________________ I understand this information
will be used by UCEMC in providing electric service
for life support equipment. Signature of Member ________________________________________________ Relation to patient __________________________________________________ OFFICE USE ONLY Cooperative Member’s Name
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