Try for free

National Grid NY Physician Protection Form

In Upstate New York, National Grid customers apply for medical protections on the Protections Application (CM6175), which names the patient's medical professional. National Grid then sends that professional its Physician Protection Form, and the clinician decides whether the household qualifies for Life Support protection or Medical Emergency protection under HEFPA. The form is not published, so it arrives per case.

Who completes it

The customer completes CM6175 online or on paper; it has no clinician section. The patient's doctor or other medical professional completes the Physician Protection Form National Grid sends and, for Medical Emergency, also sends a medical letter.

Submitting and payment

How to submit it
Return the form to National Grid's Residential Protections Team by fax or email, as directed on the form National Grid sends.
Who pays
National Grid's materials list no fee or payment for the clinician.

Good to know

  • Life Support is for households using electrically operated life-sustaining equipment; refrigerating medication generally does not count. It adds a white tag seal on the meter and outreach calls during prolonged outages.
  • If two calls during a prolonged outage go unanswered, National Grid sends emergency personnel for a wellness check; Life Support customers also get advance notice of planned outages.
  • Medical Emergency gives 30 days of protection from termination for nonpayment, extendable by 30 or 60 days; renewal requires the customer first to show inability to pay.
  • Life Support requires annual recertification, including a follow-up form sent to the provider to confirm continued eligibility.

Get the official form

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

Physician Protection Form (Life Support / Medical Emergency)

Official page

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How does a doctor get National Grid's Physician Protection Form?

National Grid sends it after the customer submits the Protections Application (CM6175), which names the patient's medical professional. The form is not published for download. The clinician completes it, chooses the protection level, and returns it to the Residential Protections Team.

What does National Grid's Life Support protection not do?

It does not protect electric service from interruption. National Grid asks Life Support households to keep a backup plan, such as a generator, batteries or relocation. The protection provides a meter tag, outreach and wellness checks during prolonged outages, and notice of planned outages.

How is National Grid Medical Emergency protection renewed?

Medical Emergency protection may be extended for 30 or 60 days depending on the patient's condition. Before National Grid asks the medical professional for an updated medical letter, the customer must show an inability to pay by submitting a financial statement with supporting documents.