Get Life Sustaining Equipment

This guide provides a comprehensive overview of how to properly fill out the Life Sustaining Equipment certification form online. By following these steps, you will ensure that all necessary information is accurately submitted to facilitate your application.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In the Customer Information section, fill in the required fields with your details, including your full name, address, account number, telephone number, and social security number.
3. Proceed to the Patient Information section. Complete this section if the patient is different from yourself by entering their name, address, telephone number, date of birth, and social security number.
4. In the Physician’s Certification section, provide the physician’s name, the practice or specialty, office address, office phone, office fax, state license number, and the date of the last examination.
5. Fill out the Medical Condition Information section. Answer the questions regarding the use of medical equipment that requires electricity, availability of alternate power supply, equipment type and model number, usage frequency, and whether it is life-sustaining equipment. Additionally, address the questions about immediate life-threatening emergencies and equipment mobility during power outages.
6. Ensure to have the attending physician sign the form in the designated area.
7. Once the form is fully completed, save your changes. You can then download or print the completed form for submission.
8. Submit the form by faxing it to the PSE&G Priority 4 Coordinator at (973) 297-4311 or mailing it to the provided address.

Complete your Life Sustaining Equipment certification online today.