When shutting off gas, electric or water service would be especially dangerous to someone who permanently lives in the home, or would make medical or life-support equipment impossible or impractical to run, a licensed clinician can sign this one-page certificate. It prevents disconnection, or gets service reconnected, for 30 calendar days. Every PUCO-regulated electric, natural gas and water utility uses the same template, adding its own name and contact details.
A licensed physician, physician assistant, clinical nurse specialist, certified nurse practitioner, certified nurse-midwife or local board of health physician completes and signs the whole form, after they or someone in their office has examined the patient. The utility fills in its name, service type and return details before handing the form to the customer.
The utility enters its company name at the top, the service at risk (gas, electric or water) in the blanks throughout the form, a contact name and phone number for questions, and the fax number for returning it. The instructions limit the form to cases where, in the clinician's professional opinion, terminating that service would be especially dangerous to the patient's health, and ask clinicians not to sign if no especially dangerous situation exists. The patient must be examined first, by the clinician or someone in their office.
Under the statement that the information provided is true to the best of the signer's knowledge, check one box: licensed physician, physician assistant, clinical nurse specialist, certified nurse practitioner, certified nurse-midwife or local board of health physician. The PUCO names these same six categories as the only professionals who may complete the certificate. The checked credential should match the license or certificate number entered at the bottom of the page.
Print the name of the patient you examined and their permanent residence, with street address on one line and city, state and ZIP code on the next. The PUCO describes the protected person as someone who permanently lives in the home, so the address should be the residence served by the utility account facing disconnection. The form asks for no date of birth, diagnosis or account number.
Check the box that fits. The first states that the patient suffers from a hazardous medical condition and that terminating the named utility service would be especially dangerous or life-threatening. The second states that the patient uses medical or life-supporting equipment and that terminating the service would make operating that equipment impossible or impractical. The utility's service type is written into each statement, so the certification covers that specific gas, electric or water service.
By signing, the clinician certifies that they advised the patient that disclosing the requested information may lead to redisclosure by the recipient, after which it is no longer protected by HIPAA rules and regulations. Have that conversation with the patient before the form leaves the office, since the signature attests that it took place.
Sign and date the authorized signature line, then print the licensed medical professional's name, business address, business telephone and current state license or certificate number. The form closes with the statement that all sections must be fully completed for the utility to process the request, so a missing license number or unchecked box can hold up reconnection. Timing matters: certificates the utility receives before 3:30 p.m. get same-day restoration.
Download the current version from the source each time; forms change without notice.
30-Day Medical Certification
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Sources for this guide
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Only a licensed physician, physician assistant, clinical nurse specialist, certified nurse practitioner, certified nurse-midwife or local board of health physician. The signer checks which of these applies, prints their name, business address and telephone, and gives a current state license or certificate number. The examination can be done by the signer or someone in their office, but it must happen before the form is signed.
No more than three times in a rolling 12-month period, and each certificate lasts 30 calendar days. If service has already been disconnected, the certificate must be used within 21 days of the disconnect date. The rules come from Ohio Administrative Code 4901:1-18-06 and apply to all PUCO-regulated electric, natural gas and water utilities.
No. It only delays disconnection, or restores service, for 30 calendar days. If it was used to prevent disconnection, the customer has to enroll in an extended payment plan before the certificate period ends or risk disconnection. The first payment on that plan is not due until the end of the certification period.
Before signing, the clinician certifies that they told the patient the information on the form may be redisclosed by the utility and would then no longer be protected by HIPAA rules. The form itself asks only for the patient's name, permanent residence and which of two qualifying situations applies, not for a diagnosis.