Critical Care Application
Complete all of the fields below. Once completed, click "submit."
Please ensure this full application is completed within 15 days.
If you require life-sustaining equipment, you will be required to fill in all required information and input your prescribing medical professional's email address.
If you do not require life-sustaining equipment but your medical condition would worsen with the loss of your power, please fill in all required information and answer no to the question "Does the patient require life-sustained equipment?" Once the form is completed, click "submit." Once submitted, you will be redirected to a new screen where you must attach one of the following documents within the last 30 days: a doctor's note, hospital discharge paperwork, or paperwork from the Home Hospice Care.
Once we have reviewed your completed online application, we will let you know if you qualify for the Critical Care program.
Thank you for the opportunity to serve you.