1. A. A navigator shall submit a complete application to the Office via email or fax.

2. B. A complete CMN Program application shall include:

   1. (1) A completed application form provided by the Office that is signed and dated by a navigator or the applicant;

   2. (2) A completed certification of serious illness or need for life support equipment form that shall include, at a minimum, the following:

      1. (a) A certification of a serious illness or the need for life-support equipment made by:

         1. (i) A licensed physician; or
         2. (ii) A certified nurse practitioner;
      2. (b) The name and address of the seriously ill person;
      3. (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;
      4. (d) The name, address, telephone number, physician or certified nurse practitioner license number, and signature of the certifying physician or certified nurse practitioner; and
      5. (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. (3) A completed application form as defined in COMAR 07.03.22.05; and
   4. (4) A termination notice issued by a fuel vendor or utility vendor.

Authority: Human Services Article, §§5-5A-07, 5-5A-08, and 5-608, Annotated Code of Maryland
(Agency Note: Federal Regulatory Reference — 45 CFR 96, Subpart H)

Effective date: July 16, 2020 (47:14 Md. R. 674)