# COMAR Title 07 — Department of Human Services

## Subtitle 03 — Family Investment Administration

### Chapter 25 — Critical Medical Needs Program

#### Regulation .04 Application Process.

*COMAR 07.03.25.04*

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.