Application for Chronic Condition or Critical Care Residential Customer Status 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1, where you will enter your name as it appears on the electric account, followed by your service address, city, state, and ZIP code. Ensure that all fields are filled accurately.
3. Locate your ESI ID on your electric bill and input it in the designated field. Circle the appropriate TDU based on the first seven numbers of your ESI ID.
4. If your mailing address differs from your service address, provide that information next. Include primary and secondary phone numbers for contact purposes.
5. Read the certification statement carefully before signing. Ensure that both you and the patient (if applicable) sign and date the form.
6. Once Part 1 is complete, forward it to the patient's physician for completion of Part 2. The physician must also sign and date this section.
7. Submit the completed application electronically to the appropriate TDU using either fax or email as indicated in the instructions.

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