Summer Crisis 2013

2999 PAYNE AVNUE, SUITE 134 CLEVELAND, OH 44114

I,__________________, here by grant authorization to my physician _______________,

PRINT FULL NAME PRINT FULL NAME

or, authorized clinic personnel ___________________ to provide specific information to

PRINT FULL NAME

Cleveland Housing Network (CHN), and/or its affiliates, and the Ohio Development Service Agency. I understand this form is solely for the issue of a cooling unit to benefit the health of a member of the household. ___________________________
PRINT PATIENTS FULL NAME

_________________________
SIGNITURE of PATIENT/PARENT or GURDIAN

______________
DATE

___________________________
PRINT PATIENTS PHONE NUMBER

PHYSCIANS DOCUMENTATION
I certify that I have examined the above patient ____________________________ and I have
PRINT NAME

determined that he/she would benefit from receiving a cooling unit.

__________________________________
HYSICIANS SIGNATURE

____________________________________
OFFICE ADDRESS CITY/STATE/ZIP

____________________________________
OFFICE TELEPHONE NUMBERS

VALIDATION STAMP REQUIRED, MEDICAL EXPIRES 30DAYS AFTER VALIDATION DATE

Agency

Address

Fax

CLEVELAND HOUSING NETWORK

2999 PAYNE Ave, Suite 134

216-574-7101

BELLAIRE PUITAS FAMICOS FOUNDATION DETROIT SHOREWAY FAIRFAX

14703 Puritas Ave, Cleve 44135 1325 Ansel Rd, Cleve 44106 3167 Fulton Rd, Cleve 44109 8111 Quincy Ave, Cleve 44104

216-671-6968 216-472-0907 216-961-9073 216-361-8653