Forms clinicians sign so a patient keeps power on, gets outage notices or a medical rate, or receives a housing accommodation or adapted phone equipment.
Utilities and regulators ask for a clinician's certification when a patient depends on powered medical equipment or would be endangered by losing service. The most common are disconnection-protection forms: Ohio's PUCO 30-Day Medical Certification, the Texas Application for Chronic Condition or Critical Care Residential Customer Status, the shared Michigan wording on DTE's form and Consumers Energy's Form 2330, and Eversource's Connecticut certification. California utilities use Medical Baseline applications such as PG&E 62-3481-B. The page also covers housing authority accommodation verifications and state telephone equipment programs.
The protection varies by program. The Ohio certificate delays disconnection 30 days and can be used at most 3 times in a rolling 12 months. Michigan forms give a 21-day medical emergency hold or annual critical-care status. Some programs, including APS's Medical Care Program in Arizona and FPL's Medically Essential Service, give outage notices rather than service guarantees. For the Texas PUCT critical care form, the physician, not the customer, sends pages 2 and 3 to the utility. 9 of these forms have a Spanish version.
A professional attests that the applicant's combined hearing and vision loss meets the NDBEDP definition of deaf-blind so the applicant can receive free communication technology.
Physician statement identifying home ventilator or LVAD use (24 hours/day) or hospice care so Entergy flags the account for medical-needs outreach during storms and outages.
Professional certifies that the applicant is deaf, hard of hearing or has a severe speech disability that creates a barrier to distance communication, for free telecom equipment/tablets.
Solicitud del Programa de Cuidado Médico
Licensed medical professional certifies that a household member depends on life-sustaining medical equipment (danger if off more than 4 hours) or has a limiting physical/mental condition, so APS gives advance notice of planned outages.
Licensed medical practitioner certifies that a patient uses a life-sustaining medical device or needs continuous electric service, so TEP flags the account for outage alerts and planned-outage notice.
62-3481-BCertifies that a full-time resident uses a life-support device or needs extra heating/cooling for a qualifying condition so the account gets the Medical Baseline allowance and outage notifications.
Licensed practitioner certifies life-support devices, heating/cooling needs and duration so the household receives the CPUC Medical Baseline allowance (16.5 kWh/day or 0.822 therms/day) and outage notifications.
SCE 14-746Certifies that a resident needs electrically operated life-support/medical devices or extra heating/cooling so the household receives the CPUC Medical Baseline allowance (extra baseline energy, outage notifications).
Certifying professional confirms the applicant's hearing, vision, speech, mobility or cognitive disability so the state program provides free specialized telephones and communication equipment.
S 504-02Tenant/applicant requests a disability accommodation (unit modification, extra bedroom, live-in aide, policy exception) and names a professional whom HACLA contacts to verify the disability-related need.
Qualified health professional certifies use of qualifying devices (electric wheelchair, home dialysis cycler, oxygen concentrator, ventilator) or extraordinary heating/cooling needs for a $15/month MED rate discount.
Physician, APRN or PA certifies serious illness (winter shut-off protection Nov 1-May 1), life-threatening condition (year-round protection) or infant protection under Conn. Agencies Regs. 16-3-100.
Physician, PA or advanced practice nurse certifies under oath that terminating electric or gas service would adversely affect a Delaware patient's health or recovery, giving Medical Alert status for 120 days.
Treating physician certifies whether a DC patient uses electrical medical/life-support equipment and whether loss of power would be immediately life-threatening, for Pepco's medical equipment notification program and serious-illness protections.
Verification letter used when a Housing Choice Voucher participant requests a disability accommodation; a physician, licensed health professional or social service/disability agency professional verifies the disability-related need.
Florida physician certifies that a patient depends on electric-powered equipment to avoid loss of life or immediate hospitalization so the account is designated Medically Essential Service (pre-disconnection and storm notices) for 12 months.
Physician, PA or licensed practitioner certifies that a resident's medical condition would be aggravated by loss of electric service, stopping disconnection for 60 days (once per 12 months; 83 Ill. Adm. Code 280.160).
Knowledgeable professional certifies a public housing or voucher household member's disability and the disability-related need for each requested accommodation; CHA decides within about 30 days.
Application for state-funded amplified, captioned, TTY or cell phone equipment; page 2 is signed by a doctor or other certifier confirming the applicant is deaf, hard of hearing, late-deafened, speech disabled or deaf-blind and cannot use a standard phone.
Physician, CRNP or PA certifies that terminating electric/gas service would aggravate a serious illness or prevent use of life-support equipment, delaying termination (customer must make a payment agreement within 30 days) under COMAR 20.31.03.
Medical, rehabilitation or service-agency professional certifies that a household member has a disability (fair housing definition) and explains the disability-related need for the requested accommodation in public housing or the leased housing (Section 8) program.
Physician or public health official certifies a medical emergency (21-day shutoff hold, up to 63 days with renewals) or critical-care status (annual hold for home medical/life-support equipment) for a DTE customer's household.
Form 2330Physician or public health official certifies a medical emergency (21-day shutoff hold, max 63 days) or critical-care customer status (annual) for a Consumers Energy household.
Approved certifier confirms the applicant's vision, hearing, speech, physical or cognitive disability for the state TAP for Telephone, TAP for Internet and TAP Wireless Pilot equipment programs; valid 3 years.
Attending medical professional certifies life-sustaining electric equipment (use frequency, backup power, immediate danger in an outage), protecting service from disconnection for 90 days and enrolling the customer in outage notifications.
Registers a household member who depends on life-support equipment and certifies a medical emergency so Con Edison applies HEFPA shut-off protections and outage priority.
Medical professional chooses Life Support (electric life-sustaining equipment; meter tag and outage outreach) or Medical Emergency (30-day termination hold, extendable) protection for a household under New York HEFPA.
Licensed medical professional certifies that disconnecting gas, electric or water service would be especially dangerous to a resident's health or make medical/life-support equipment inoperable, delaying disconnection 30 days (Ohio Adm. Code 4901:1-18-06).
Licensed physician, NP or PA certifies a diagnosed condition, the electrical equipment/services needed, and how losing power would endanger the patient (OAR 860-021-0410), for PGE's medical certificate program and payment flexibility.
Professional certifies the applicant's disability (deaf, hard of hearing, blind, low vision, deafblind, speech, cognitive or physical) and need for specialized telephone or wireless equipment.
Physician certifies that a resident depends on an electric-powered medical device to sustain life (critical care) or has a serious condition needing electric devices or heating/cooling (chronic condition), so the transmission and distribution utility grants the status and its notice/disconnection protections.
Solicitud del Programa de Cuidados Críticos
Attending physician certifies that a patient at the residence requires electric-powered medical equipment (or electric heating/cooling) so the household gets extra time to pay under CPS Energy's Critical Care program.
Physician certifies that a customer or household member has a serious medical condition (with any powered equipment, refrigeration or HVAC needs) so regulated electric and water utilities limit disconnection under 20VAC5-330.
DSHS 14-264Application for the TED program; a professional certifies the applicant's hearing loss or speech disability and that the requested equipment will help.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A licensed physician, PA, clinical nurse specialist, CNP, certified nurse-midwife or local board of health physician certifies that disconnecting gas, electric or water service would be especially dangerous to a resident's health or would make medical equipment inoperable. It delays disconnection 30 days, can be used at most 3 times in 12 months, and must be used within 21 days of a disconnection. If the utility receives it before 3:30 p.m., service must be restored the same day.
A licensed physician or surgeon, DO, nurse practitioner or physician assistant signs Form 62-3481-B, listing life-support devices and any extra heating or cooling need. The application must reach PG&E within 90 days of the practitioner's signature, by mail, by email, or through the online application, which sends instructions to the doctor. Non-permanent conditions are recertified with the practitioner every 2 years.
Some delay it for a set time and some do not. Maryland's PSC-801, Atlantic City Electric's Life Sustaining Equipment Certification, ComEd's medical certification and the Ohio certificate delay disconnection for a limited period. Notification programs, such as Pepco's Emergency Medical Equipment program, TEP's Medical Device Alert and Entergy's medical needs registration, only flag the account for outage notices and do not prevent disconnection for non-payment.
Housing authorities ask a knowledgeable professional to verify the disability and the disability-related need for the requested accommodation. The Boston Housing Authority's Certification of Need covers public and leased housing, and a letter on letterhead may substitute. The Chicago Housing Authority takes certifications only through its online portal, one per professional. In Los Angeles, HACLA contacts the verifier the tenant names, and the DC Housing Authority uses ADA Form 845 for voucher participants.