Get Ct United Illuminating Company Physicians Certification Of Illness Form For Ui Customers 2013-2025

Filling out the CT United Illuminating Company Physicians Certification Of Illness Form is an important process for users seeking protection from service shutoff due to serious health issues. This guide will help you navigate the online form to ensure accurate completion.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the patient’s name in the designated field. This is crucial for identifying the individual who is ill.
3. Fill in the patient’s UI account number. This number allows the utility company to link the certification with the user’s account.
4. Provide the patient’s address in the specified fields, ensuring accuracy to prevent any processing delays.
5. Select the illness classification by checking the appropriate box, either ‘Serious Illness’ or ‘Life Threatening’. This determines the urgency of the situation.
6. Indicate if the life-threatening situation requires the use of electrically operated equipment by checking either ‘Yes’ or ‘No’.
7. Select the estimated length of the serious or life-threatening situation by checking the corresponding box.
8. Enter the physician’s name, address, telephone number, fax number, and provider state license number in the relevant fields.
9. Physician must sign and date the form, certifying the information provided is accurate to the best of their knowledge.
10. After reviewing all entries for accuracy, you can save changes, download, print, or share the completed form.

Complete your certification form online today to ensure continued utility protection.