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Medical Certification Form

Medical Certification Form

Medical Certification Form

To apply for a Medical Emergency or Critical Care Shutoff Protection, customers must complete the Medical Certification Form which must be certified by a physician or a public health official. Information provided by the physician or public health official should be provided in English in order to avoid delays in processing the application. The Medical Certification Form is available from your utility or many be accessed below.
English

Other Languages

Arabic

عربي

Bengali

বাংলা

Chinese (Simplified)

简体中文）

Japanese

日本語

Korean

한국인

Russian

Русский

Spanish

Español

Vietnamese

Tiếng Việt
To learn more about shutoff protections, click here.