Get Nicor Medical Certificate

Filling out the Nicor Medical Certificate is an important process that helps ensure the well-being of individuals facing medical challenges. This guide will provide you with clear, step-by-step instructions to assist you in completing the form online accurately and efficiently.

Follow the steps to complete your Nicor Medical Certificate online.

1. Press the ‘Get Form’ button to access the Nicor Medical Certificate form and open it for editing.
2. Begin filling in the Nicor gas account number in the designated space. Ensure all information is accurate to avoid delays.
3. Enter the phone number associated with the account holder in the appropriate field.
4. Provide the full name of the patient in the designated area. This should be the individual experiencing the medical condition.
5. Input the patient's date of birth in the corresponding section to verify their identity.
6. Fill in the name of the parent or account holder in the relevant field, if applicable.
7. Enter the phone number of the parent or account holder for communication purposes.
8. Complete the street address of the residence where the patient lives.
9. Input the city where the patient resides.
10. Write a statement that explains how the termination of gas service will aggravate the patient’s current medical condition, including how long they have been under care.
11. Designate the certifying party as either a registered physician or a local board of health in the appropriate section.
12. Fill in the certification date to indicate when the form is being completed.
13. Provide the name and phone number of the certifying party, ensuring that this information is accurate.
14. Complete the facility’s street address and city for the certifying party.
15. Include the fax number of the certifying party if required.
16. Ensure the certifying party signs the form. They should also include their license number.
17. Review all filled fields for accuracy and completeness before saving changes or transmitting the form.
18. Finally, save the changes made to the form, then download, print, or share the completed document as needed.

Take action now by completing your Nicor Medical Certificate online to ensure your needs are met promptly.