EMWD Assist Application Submission

Medical Report Form

To qualify for EMWD Assist, you must be able to provide certification of a primary care provider that “discontinuation of residential water service will be life threatening to, or pose a serious threat to the health and safety of, a resident of the premises where residential water service is provided.”
Click here to find the Medical Certificate Form
Please upload a signed medical certificate from a primary care provider:*

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UPLOAD PROOF OF ENROLLMENT*

Please upload your proof of enrollment. For example, a utility bill or other household bill which notates enrollment and/or benefit receipt, or a letter from the above selected program.
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Customer Name*

First NameLast Name
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address*
example@example.com
Phone Number*
Confirm E-mail Address*
example@example.com
Should be Empty:

Medical Report Form