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LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) PHYSICIAN/NURSE MEDICAL STATEMENT
Date:
Patient/Client Name:
County:
Dear Physician/Nurse:
The above-named patient/client has applied for LIHEAP Crisis Assistance. This program provides emergency utility (heating or cooling) assistance to eligible low-income persons who have a verifiable medical situation caused (or aggravated) by extreme heat or cold weather. It is not required that the patient be seen again by you only for the purpose of completing this form. Please complete this form and return to me.
In my opinion, this patient does have a medical situation caused (or aggravated) by extreme heat or cold.
In my opinion, this patient does not have a medical situation caused (or aggravated) by extreme heat or
cold.
I cannot make a determination at this time because (Explain):
Physician/Nurse Signature or stamp
Date
______________________________ Printed Name of Physician or Nurse
_______________________
Phone Number
Sincerely,
Agency Employee
Community Action Agency
LIHEAP-124 Reviewed 2024