Dominion energy forms 2026

1. Click ‘Get Form’ to open the Serious Medical Condition Certification Form in the editor.
2. Begin by filling out your personal information in the 'To Be Completed by the Customer' section. Include your name, address, electric and water account numbers, and contact telephone numbers.
3. In the next section, have the patient or their legal guardian complete their details. This includes their name, relationship to you, and contact information.
4. The physician must then fill out their section. Ensure they provide their name, office address, contact details, and current license number along with the patient's diagnosis and required treatments.
5. Check all applicable medical equipment that is prescribed for the patient’s condition. This may include items like a mechanical ventilator or CPAP machine.
6. Finally, ensure all signatures are obtained where required before submitting the form via email or mail as instructed.

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