Request for Priority Sevice
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LIFE SUSTAINING EQUIPMENT -- REQUEST FOR PRIORITY SERVICE
Date 12/lo/lg
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Dear Sir or Madam:
To:
My child B b er/ A/II p1t2/1tS has a serious medical condition which
requires the use of the following life sustaining equip~ent: 1/~()ltI tXjJ'en S',rC;y.t'#f/
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When there is an emergency or you are notified that we are experiencing a problem,
PLEASE RESPOND IMMEDIA TEL Y. Also, you must notifiy us of any planned interruption in
servIce.
My child's physician is !Jjt(... fa t~; , phone rf1 ~ -g 3 7D
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Our address is It r1 frO II JJl'lrJ e...
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Our phone is 9/ V - ~ tf gJ - ? / I 7
Our nearest cross street is !l:iL ~f? Is )J,f.
We live in a private home V' apartment
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Please return the enclosed confinnation. Thank you.
Sincerely yours,
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Parent's Name
Lynn Fielden-Smith, Health Care Advocacy
28 Beach Road, Ossining, New York 10562. 914-762-8815.
We have received notification of the priority needs of
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LIFE SUST AlNING EQUIPMENT - REQUEST FOR PRIORITY SERVICE CONFIRMATION
who
To report an interruption of service or obtain emergency assistance, please call the
following Hotline Number
You will need to renew your request for priority service each
Signed
Printed Name
Title
Organization
Date
Please return to:
Lynn Fielden-Smith, MS, MPH
Health Care Advocacy
28 Beach Road
Ossining, New York 10562
Lynn Fielden-Smith, Health Care Advocacy
28 Beach Road, Ossining, New York 10562. 914-762-8815.