Critical care form 2026

1. Click ‘Get Form’ to open the critical care form in the editor.
2. Begin by filling out Part 1 on PAGE 2. Enter your name as it appears on the electric account, followed by the patient's name who requires critical care status.
3. Provide the service address found on your electric bill, along with your mailing address if it differs from the service address.
4. Fill in the ESI ID, which can also be found on your electric bill, and select your TDU based on the first seven numbers of your ESI ID.
5. Complete the contact information section, including primary and alternate phone numbers. Ensure you provide an emergency contact name or state that you choose not to provide one.
6. Review all entered information for accuracy. Sign and date the application to certify that all information is correct.
7. Once completed, forward PAGE 2 and PAGE 3 to the patient’s physician for their input and signature before submission.

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