Md. Code Regs. 07.03.25.04

Current through Register Vol. 52, No. 1, January 10, 2025

Section 07.03.25.04 - Application Process

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.

Md. Code Regs. 07.03.25.04

Regulation .04 adopted effective 47:14 Md. R. 674, eff. 7/16/2020