Consumers Energy customers in Michigan use this MPSC-approved Medical Certification Form to hold off shutting off gas or electric service, or to restore it. A physician or public health official certifies either a medical emergency, which postpones shutoff 21 days per certificate up to 63 days, or a critical care patient on home life-support equipment, which postpones shutoff for a year.
The patient, or a parent or guardian for a patient under 18, completes Section 1 and authorizes release of the medical information; the account holder completes Section 2. The physician or public health official completes Section 3: the condition type, conditions, equipment and time period, license number, contact details and signature.
Download the current version from the source each time; forms change without notice.
Medical Certification Form
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.
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A certified medical emergency postpones shutoff for 21 days. Additional certificates are needed to extend it, and the total postponement for medical emergencies cannot exceed 63 days. A critical care certification postpones disconnection on an annual basis and must be renewed with a new form each year.
Medical emergency covers an existing condition of a household member that losing utility service would aggravate. Critical care covers a patient who uses life-supporting medical equipment at home, where termination would be immediately life threatening. The clinician checks one box and lists the conditions or equipment.
The form names physicians and public health officials. Section 3 asks the signer to check physician or public health official and, if not a physician, give a job title, along with a license number. Consumers Energy's definitions also refer to certification from a physician or medical facility for critical care.