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Serious Medical Condition Certification Form

'Serious medical condition' means a physical or psychiatric condition that requires medical intervention to prevent further disability, loss of function, or death. Such conditions are characterized by a need for ongoing medical supervision or the consultation of a physician. Serious medical condition carries with it a risk to health beyond that experienced by the majority of children and adults in their day-to-day minor illnesses and injuries. Individuals with a serious medical condition may require administration of specialized treatments and may be dependent on medical technology such as ventilators, dialysis machines, enteral or parenteral nutrition support, or continuous oxygen. Medical interventions may include medications with special storage requirements, use of powered equipment, or access to water.

The Code of Virginia 20VAC5-330 established guidelines or limitations on the termination of electric service to persons with serious medical conditions and provides the utility with a completed Serious Medical Condition Form.  If you feel that you or a family member living with you qualify as having a serious medical condition you may print this form and have your physician complete the information required. The completed form must be returned to Southside Electric Cooperative. Any form returned that is not complete will be returned to the customer.

Serious Medical Condition Form