Code of Maryland Regulations (Last Updated: April 6, 2021) |
Title 07. Department of Human Services |
Subtitle 03. FAMILY INVESTMENT ADMINISTRATION |
Chapter 07.03.25. Critical Medical Needs Program |
Sec. 07.03.25.04. Application Process
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A. A navigator shall submit a complete application to the Office via email or fax.
B. A complete CMN Program application shall include:
(1) A completed application form provided by the Office that is signed and dated by a navigator or the applicant;
(2) A completed certification of serious illness or need for life support equipment form that shall include, at a minimum, the following:
(a) A certification of a serious illness or the need for life-support equipment made by:
(i) A licensed physician; or
(ii) A certified nurse practitioner;
(b) The name and address of the seriously ill person;
(c) A statement that the seriously ill person or person in need of life-support equipment is the applicant or an occupant of the premises in which the applicant resides;
(d) The name, address, telephone number, physician or certified nurse practitioner license number, and signature of the certifying physician or certified nurse practitioner; and
(e) A statement that termination of electric, gas, or other energy source service will aggravate a serious illness or prevent the use of life-support equipment;
(3) A completed application form as defined in COMAR 07.03.22.05; and
(4) A termination notice issued by a fuel vendor or utility vendor.