This form has a section that needs to be filled out by your doctor. You can type in all of your required information and print the application. Once completed by your Physician, it must be returned directly to us from your Physician. This application can be returned by Email to: firstname.lastname@example.org OR Mail to: JXN WATER PO BOX 4505, JACKSON, MS, 39216.
Please note: This form expires yearly. We will not inform you when the form is about to expire and is solely your responsibility to resubmit a new form. It will only protect your account for up to 60 days if it goes into disconnection during this timeframe. It is imperative that you have a medical backup plan in case of an outage. It is your responsibility to make appropriate arrangements in an emergency.