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Template Letter: Electric Company Notification Return Address Line 1 Return Address Line 2 Date (Month, Day, Year) Full Name of Recipient Title/Position/Department of Recipient Name of Electric Company Address Line 1 Address Line 2 To Whom It May Concern: This letter is in regard to one of your customers, whose identifying information appears below, and who has a life-sustaining device that is dependent on electrical power supply: Patient Name Patient Address Patient City, State Zip Patient Telephone Number Account Number Name of Patient has an implanted “heart pump” or a ventricular assist device (VAD), called the HVAD® System, manufactured by HeartWare, Inc. The HVAD® System assists a patient's weakened heart to pump blood throughout his or her body. Name of Patient is to be discharged home on date following hospitalization for surgical placement of the HVAD® System. Name of Patient requires access to an electrical source at all times to maintain his life support equipment. As a result, the electrical service should not be interrupted and any power outages that affect the home should be considered a critical priority for restoration. It is important that you give special attention to power lines and equipment repairs in Name of Patient’s area. If you have any questions regarding the VAD, please feel free to contact us at the implant center listed below. Additional information on the VAD is also available on the manufacturer’s website: www.heartware.com Implant Center Name Implant Center Address Line 1 Implant Center Address Line 2 City, State Zip Phone Number Sincerely, Name of Implanting MD Phone Number Page 1 of 1 GL1093 Rev01 11/14