Critical Medical Needs Program Intake Form

If none, use [email protected]
  • 211
  • BGE
  • DSS
  • GEDCO
  • Other (Please add your agency in the notes)
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  • On
  • Termination Notice
  • Service Off
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Document Upload

Examples could be:

  • Signed Physician Certification

  • Government ID

  • Proof of Residence

  • Social Security # Documentation

  • Proof of Income (If Applicable)

  • Electric Bill (If Applicable)

  • Heating Bill (If Applicable)

Optional (but recommended)