Community Solar Signup for Hennepin Health Care

Patient Information

These fields must be completed to refer your patient. If the patient doesn't have an email please fill in that field with the patient's last name and the numbers of todays date @fakemail.com. If they don't have a phone number enter 555-555-5555. If they have more than one phone or email put additional contact info in the Questions/Notes field at the bottom of this form.

Name

Email Address

Phone Number

Street Address

City

State

Zip Code

Energy Bill Information

This information is available on the patient's Xcel Energy bill. If a bill is not available Xcel customer service (800-895-4999) can provide it if you call them with the patient.

Billing Address

Same address as above

Street Address

City

State

Zip Code

Customer of Record

List your customer name exactly as it appears on your electric utility bill. [show me where]

Energy Bill Account

List your account number exactly as it appears on your electric utility bill. [show me where]

Energy Bill Premise

List your premise number exactly as it appears on your electric utility bill. [show me where]

Attach Documents Here

Upload Xcel bill and income verification (photo or scan) as a single attachment

Questions/Notes

Enter any other specific patient information, including language needs, that you want us to be aware of here.