TITLE 47: HOUSING AND COMMUNITY DEVELOPMENT
CHAPTER I: DEPARTMENT OF COMMERCE AND ECONOMIC OPPORTUNITY
PART 100 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
SECTION 100.APPENDIX B MEDICAL CERTIFICATION



Section 100.APPENDIX B Medical Certification

 

Please fill out this statement and return to the following address:

 

I certify that

 

suffers from a serious

health condition which can be ameliorated by cooling facilities. Illness or medical condition:

 

 

 

 

Asthma

 

 

 

 

Respiratory Allergies (requiring filtered air)

 

 

 

 

Severe obstructive lung disease

 

 

 

 

Severely debilitating stroke

 

 

 

 

Any medical condition of a non-ambulatory patient

 

 

 

 

Other please specify:

 

 

 

 

 

 

Signature:

 

 

 

 

Name and Title/Degree:

 

 

 

 

Practice or Organization Name:

 

 

 

 

Registration No.

 

 

 

I hereby authorize this agency to verify that information provided by me and to contact my physician or other public health official for the purpose of securing medical certification as described above.

 

Name of Applicant

 

Signature of Applicant

 

Date

 

Social Security Number of Applicant

 

 

(Source: Appendix B recodified from 89 Ill. Adm. Code 109.Appendix B at 33 Ill. Reg. 9466)