APS :: APS Medical Care Program

About APS

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APS Medical Care Preparedness Program

* required information

Your health and safety is a top priority at APS.

We make special provisions for medical conditions that could be jeopardized by an interruption of electrical service. If you or someone living in your home relies on electrically-operated medical equipment, please let us know today, so we can send you information to prepare you in the event of an electrical outage.

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Customer Information
* APS account number (nine digits)
* Your first name	* Your last name
* Service address line 1
Service address line 2
* City, state, zip ,
* Daytime phone number - -	E-mail address
Patient Information
* Patient's first name	* Patient's last name
* Medical condition
* Medical equipment	* Frequency/duration of use
* Attending physician	* Attending physician phone number - -
Physician e-mail address (if known)



Additional Notes & Agreement
Comments
* I do hereby authorize disclosure of information listed on this form.