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Eversource CT Medical Certification of Illness Form

Eversource uses this form to protect Connecticut residential customers from shutoff for nonpayment under Connecticut regulation 16-3-100. The clinician picks one classification: serious illness (protection November 1 to May 1), life-threatening (year-round protection), or infant protection for a child under two discharged from the hospital. Clinicians can complete it on paper or on Eversource's Medical Web Portal.

Who completes it

A registered physician, APRN or PA completes the whole form: classification, whether a life-threatening condition requires electric equipment, expected length, patient name, account number and address, clinician details, signature, state license number and date.

Submitting and payment

How to submit it
Fax or mail the paper form to Eversource within seven days of receipt, or certify through the secure Medical Web Portal, where Eversource asks clinicians to finish within 14 days.
Who pays
The form lists no fee for the clinician's certification.

Good to know

  • If no length of illness is selected, the form must be renewed every 15 days, and every certification must be renewed at least annually.
  • The electric-equipment question is not required for certification; Eversource uses it only for reconnection during outages.
  • Infant protection also requires the household to document financial hardship, such as proof of income for adults over 18.
  • Eversource may contest a certification under state regulations, and the customer must keep paying current bills and arrange payment of past-due amounts.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Certification of Illness Form for Eversource Connecticut Residential Customers

Official pagePDF

Fill it with Vero

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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How this list is checked

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.

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Frequently asked questions

How long does Eversource's Connecticut medical protection last?

It follows the length the clinician selects: 1 month or less, 1 to 3, 3 to 6, 6 to 9, or 9 to 12 months. If no length is specified, the form must be renewed every 15 days, and all certifications must be recertified at least annually.

What is the difference between serious illness and life-threatening on the Eversource form?

Serious illness means the patient is seriously ill but losing gas or electric service will not endanger their life; the household is protected from shutoff for nonpayment between November 1 and May 1. Life-threatening means losing service will endanger the patient's life, and protection applies year-round.

Can clinicians complete the Eversource form online?

Yes. Registered physicians, APRNs and PAs can complete the medical certification of illness on Eversource's secure Medical Web Portal, which Eversource asks them to do within 14 days. The paper form can instead be faxed or mailed within seven days of receipt.