Puc critical care fillable form 2025

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4.3 out of 5

30 votes

The document is an application form for obtaining Critical Care or Chronic Condition status with a utility provider in Texas. It outlines the necessary steps for customers and their physicians to complete the application, including required information and contact details for various utility companies. The document emphasizes that submission of the application does not guarantee status approval, and customers remain responsible for paying their electric bills.

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Click ‘Get Form’ to open the Puc critical care fillable form in the editor.
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 and service address. Ensure all fields are completed accurately.
Provide your ESI ID, which can be found on your electric bill. Circle the appropriate TDU based on the first seven digits of your ESI ID.
Complete the contact information section, including primary and alternate phone numbers. Don’t forget to include an emergency contact name or indicate that you choose not to provide one.
Sign and date the application at the bottom of Page 2, certifying that all information is correct.
On Page 3, ensure that the patient’s physician fills out their section completely, including their signature and Texas Medical Board License Number.
Once both pages are completed, submit them via fax or email to the appropriate TDU as indicated in the instructions.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (143 Votes)
2014	4.3 Satisfied (30 Votes)
2010	4.9 Satisfied (55 Votes)

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