Get Puc Critical Care Fillable Form

Filling out the Puc Critical Care Fillable Form online is essential for individuals seeking critical care or chronic condition status with their utility provider. This guide will walk you through each section and field of the form to ensure your application is completed accurately and efficiently.

Follow the steps to fill out the form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin with Part 1, entering all required customer information. This includes your name as it appears on the electric account, the patient's name, service address (as found on your electric bill), and mailing address if it differs.
3. Ensure you fill in the ESI ID and select the appropriate TDU based on the first seven digits of the ESI ID provided.
4. Complete the contact information fields. Input your primary and alternate phone numbers, and provide emergency contact details. If you choose not to provide an emergency contact, include the statement in the space provided.
5. Read the certification statement carefully and provide your signature and date. The patient’s guardian or managing conservator should also sign and date the form.
6. Proceed to Page 3 for the physician's section, where the patient’s physician must confirm the medical conditions as applicable. They should answer the relevant questions regarding the patient's dependency on electric-powered medical devices.
7. The physician needs to print their name, Texas Medical Board License Number, and contact information, followed by their signature and date.
8. Once the form is fully completed, ensure all information is accurate and legible. You can then save changes, download, print the form, or share it as required before submission.

Ensure that you complete and submit the Puc Critical Care Fillable Form online for your critical care or chronic condition status.