Eversource Medical_Protection_Plan_Certification_Form

To be completed by a Registered Physician, Advanced Practice Registered Nurse (APRN), or Physician Assistant (PA). 
Medical Certification of Illness Form 
 
 
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 MEDICAL CERTIFICATION OF ILLNESS FORM FOR EVERSOURCE RESIDENTIAL CUSTOMERS  
Eversource will provide protection from a service shut-off if a Registered Physician, Advanced Practice 
Registered Nurse (APRN), or Physician Assistant (PA), certifies the patient listed below is seriously ill, has a 
life-threatening situation, or qualifies for infant protection. See Conn. Agencies Regs. § 16-3-100. 
 
Please review the classifications listed below and select the one that best describes your patient’s 
condition. 
 
□ Serious Illness: 
My patient is seriously ill. However, not having gas or electric service will not endanger 
the life of my patient. The household is protected from a service shut-off for 
nonpayment between November 1 and May 1. 
□ Life-Threatening: 
My patient has a medical condition and not having gas or electric service will 
endanger the life of my patient. The household is protected from a service shut-off for 
nonpayment year-round. 
□ Infant Protection: 
Patient is a child under the age of two who is discharged from the hospital and needs  
utility service for health and well-being. The household is protected from termination for 
nonpayment until the protection expires or the child turns two years old.  
 
Does the life-threatening situation require the use of electrically operated equipment? □Yes □No 
 
(Not required for certification; needed solely for purposes of reconnection during an outage) 
 
Please select the length of the serious or life-threatening situation. 
□ 1 month or less   □ 1-3 months   □ 3-6 months   □ 6-9 months   □ 9-12 months    
This form must be completed every 15 days if no length of illness is specified and must be recertified at least annually. 
Patients should contact their utility to enter into a payment arrangement to pay their utility bills. 
 
  
*Patient’s Name:  
 
 
                         *Utility Account Number:  
 
 
 
 
 
*Patient’s Address:     
 
 
 
 
 
 
 
 
 
              
 
*Physician/PA/APRN’s Name:   
        
 Physician/PA/APRN’s Address:   
    
*Physician/PA/APRN’s Telephone Number: 
 Fax Number:   
 
 
*Physician/PA/APRN’s Signature: 
*Medical State License #:   
 
 
*Date:   
 
  
* Information required to process certification form.  
 
 
Please return the completed form by fax or mail to Eversource within seven (7) days of receipt.  
 
Eversource Energy c/o Credit & Collections 
 
Telephone: 
1-800-286-2828  
1985 Blue Hills Ave Ext. 
 
 
 
Fax: 
 
1-800-238-4067  
Windsor, CT  06095  

To be completed by a Registered Physician, Advanced Practice Registered Nurse (APRN), or Physician Assistant (PA). 
Medical Certification of Illness Form 
 
 
Page 2 of 2 
 
 MEDICAL CERTIFICATION OF ILLNESS FORM FOR EVERSOURCE RESIDENTIAL CUSTOMERS  
 
 
                                                    
CUSTOMER INFORMATION 
 
 
  If different from patient information:  
   Utility Account Holder’s Name:   
       
   Street Address:    
    
   State: 
Zip Code:   
 
   Customer Telephone Number: 
                                                               
 
 
 
 
CUSTOMER AUTHORIZATION 
 
I authorize Eversource to certify with my Registered Physician, Advanced Practice Registered Nurse 
(APRN) or Physician Assistant (PA), that my medical condition is a serious illness or life-threatening 
situation. 
 
Patient, Guardian or Conservator’s Name (Print):   
 
 
Patient, Guardian or Conservator’s Signature:   
 
 
 
 
 
 
The utility has the right to contest the validity of any Medical Certification of Illness form before the  
Public Utilities Regulatory Authority. See Conn. Agencies Regs. § 16-3-100 (e) (1) and (e) (5). 
 
 
 
    During outage events, if you provide us with information regarding life support equipment operating at a service   
    address, municipal authorities will be provided with the service address where such equipment is operating.  
    This information is shared consistent with state regulations.