Regulation .04 Application Process.
Regulation .04 Application Process.LinkCopy Citation
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.