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Ohio » Special Assistance » Medical Certificate Request

Medical Certificate Request

The following information needs to be provided in its entirety.  Without this information, Duke Energy will be unable to process the request for a Medical Certificate.  If the customer is eligible, the Medical Certificate will be faxed to the physician's office for completion.

Please Note: 

  • Physician's office requesting this form does not guarantee approval.
  • Request completed before 4:00 p.m. will be faxed same day.  If received after 4:00 p.m. the medical certificate will be faxed next business day.

**Attention:   If Services have been DISCONNECTED, Please call 1-800-544-6900. **

* Indicates a required field.

Duke Energy Account Holder Information

Please enter an account number.

Account Number is located in the upper left corner of your bill. Sample bill - account number location

Please enter the account holder's first and last name.

Please enter account holder's service address.

 

Please enter account holder's city.

 

Please enter account holder's state.

 

Please enter account holder's zip code.

Please enter the first and last name of the ill person.

Please enter the ill person's date of birth.

mm/dd/yyyy
Physician's Information

Please enter the first and last name of the doctor.

Please enter the doctor's phone number.

xxx-xxx-xxxx ext. xxxxx
ext.

Please enter the doctor's fax number.

xxx-xxx-xxxx

Please enter the doctor's address.

 

Please enter the doctor's city.

 

Please enter the doctor's state.

 

Please enter the doctor's zip code.

Please Verify

Please enter the text that appears in the image below.