Medical baseline allowance application

Even with a O2 Pump working it's not close to what's used. $5 to $10 for XPAP and $20 for the O2 unit Max. My Electric bill is high, and it's $1400 a year ( With Air, Gas Heat) Jim. Use data to optimize your xPAP treatment! "The art of medicine consists in amusing the patient while nature cures the disease."

Superscript text contains small letters that appear above the type's baseline. Exponents ('²') appear in superscript text, as do ordinal indicators ('1ˢᵗ') and trademark symbols ('...The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts.Start, Stop, and Move. Gas Appliance Check. Power Quality. Letters of Credit or Residency. Request Change of Mailing Address. Request Name Change on Account. Continuity of Service Agreement. Letter of Authorization. Service Upgrade for Your Home or Business. 2. If the doctor certifies the resident’s medical condition is not permanent, PG&E will require completion of a resident’s eligibility for Medical Baseline each year and completion of a new application with a doctor’s certification every two years. 3. If the resident has a vision disability, I may contact PG&E to request special ... The standard Medical Baseline allowance is 16.5 kilowatt-hours of electricity and/or 0.822 therms of natural gas per day, which is in addition to your daily standard Baseline allocation. If this allowance does not meet your medical needs, please contact SDG&E at 1-800-411-7343 to discuss additional amounts. SDG&E offers TDD/TTY at 1-877-889-7343. The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. Yes. Medical Baseline Allotment and California Alternate Rates for Energy Program (CARE) are two separate programs. Medical Baseline Allotment is not based on income. Customers may qualify for both programs. If you qualify for the CARE benefit, you receive a discount on gas and electric rates. If you may qualify for Medical Baseline Allotment ...

Learn how to apply for the Medical Baseline Allowance program that provides extra electricity for medical equipment or devices. Find out if you qualify, what devices are eligible, and how to recertify every 2 to 4 years.Are you a pre-medical student looking to gain hands-on experience in the medical field? A pre-medical summer internship may be just what you need to kickstart your career and set y...Distilled water is a type of purified water that has undergone a distillation process to remove impurities and contaminants. This highly purified form of water is commonly used in ...How do I recertify for the Medical Baseline Program? If you are an active Medical Baseline customer with a non-permanent medical condition and need to recertify for continued eligibility, please visit the Apply for the Medical Baseline Program page and follow the steps to complete the application process. SUBMIT FEEDBACK. If you are an …MEDICAL BASELINE ALLOWANCE APPLICATION . Patient’s Last Name: First Name: PART 2: TO BE COMPLETED BY A MEDICAL PROVIDER (LICENSED MEDICAL DOCTOR [M.D.], DOCTOR OF OSTEOPATHY [D.O.], NURSE PRACTITIONER [N.P.] OR PHYSICIAN’S ASSISTANT [P.A.]) I certify that the medical condition and needs of my …Key Takeaways: The SCE Medical Baseline program offers an additional 16.5 kWh of electricity per day for eligible households.; Eligibility criteria include the regular use of electrically powered medical or life support equipment. Application can be done online or by downloading and mailing the SCE Medical Baseline Allowance form.; Participating …

The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day, which is in addition to to your daily Standard Baseline Allocation. MORENO VALLEY UTILITY MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED … Anyone can apply for Medical Baseline Allowance. To apply, complete Part 1 of the attached application. Next, have a doctor complete Part 2 of the application certifying the need for additional heat due to the medical condition. Don’t forget to make a copy for your files. Mail the completed application to: Southern California Gas Company ... The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. Anyone with a qualifying medical need can apply for the allowance. You can also apply even if you pay for your energy through your landlord or property owner. If your landlord …

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How To Apply. To apply for the program by mail, complete the application and send it in with your doctor's note to: City of Colton Utility BillingHow To Apply. To apply for the program by mail, complete the application and send it in with your doctor's note to: City of Colton Utility BillingYou can obtain an application for this program by calling BVES at 1-800-808-BVES(2837). A certification from a doctor, physician assistant, or nurse ...Even with a O2 Pump working it's not close to what's used. $5 to $10 for XPAP and $20 for the O2 unit Max. My Electric bill is high, and it's $1400 a year ( With Air, Gas Heat) Jim. Use data to optimize your xPAP treatment! "The art of medicine consists in amusing the patient while nature cures the disease."Customer Signature: Date: ICAL DO TOR (M.D.) OR DOCTOR. PART 1 TO BE COMPLETED BY CUSTOMER (please print) (11-0700.v2.01/16 BPDI) Page 2of 28800-1000-400-0013. MEDICAL BASELINE ALLOWANCE APPLICATION Used for Medical Baseline Enrollment and Re-Certification. OF OSTEOPATHY (D.O.). I certify that the …Medical Baseline is a financial assistance program for eligible residential customers who have additional energy needs due to certain qualifying medical conditions. The Medical Baseline Program will increase a customer's baseline allotment, allowing them to use more energy at the lowest price for their chosen rate. If you are on a rate program ...

For Medical Baseline Program Enrollment and Recertification. STEP 1. Account and Customer Information (Please print.) PG&E CUSTOMER ACCOUNT NUMBER. CUSTOMER FIRST AND LAST NAME (as it appears on PG&E bill) RESIDENT WITH MEDICAL CONDITION FIRST AND LAST NAME (the customer or a full-time resident in the service address) SERVICE ADDRESS APT NUMBER.Looking to cash in on the summer’s coming travel boom, Amtrak is offering another buy-one-get-one-free discount for its roomette sleeper accommodation, which allows you to book a c...How to Apply. Apply Online. Download Medical Baseline Allowance Application. Download Medical Baseline Allowance Application (Spanish) To learn more, contact your local Liberty office at 1-800-782-2506 (electric customers only).The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12.The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If you are on an electric rate without a baseline, you may be eligibleIRS rules allow taxpayers to deduct medical expenses that exceed 7.5 percent of a taxpayer's adjusted gross income (generally wages plus other income, such as interest and dividend...1-800-DIAL-DWP (1-800-342-5397) Hearing/Speech Impaired (TDD) (1-800-432-7397) Send us an email. A discount on electric bills are available to customers who provide verification by a state-licensed physician that a full-time member of the household has a qualified medical condition.Qualifying Medical-Based Need ; Help Someone Avoid Disruption of Service ; Assistance for Those with Limited Vision; Referrals to Social Services Agencies ; One-time Assistance Bill Assistance ; Low Income Federal Financial Aid for Qualifying Customers ; Savings Center. Overview; Tips. Home Electrification; Take a Home Energy Survey ...Once you’ve completed an application and obtained verification from your licensed physician, surgeon or osteopath, an additional monthly medical allowance of 25 therms will be provided at the lowest (baseline) rate for hemiplegic / paraplegic / quadriplegic persons, multiple sclerosis / scleroderma patients and persons who are being treated for a life-threatening illness and have a ... We and other third parties, such as Meta and Google, use cookies and other tracking technologies to personalize content and ads on our site and other sites, to measure and analyze advertisements, and to optimize site functionality.

Medical Baseline . 2 . CHECK YOUR EMAIL FOR YOUR . P.O Box 8329 . Stockton, CA 95208 . CONFIRMATION CODE. Share the code with your medical . To request a paper application in . practitioner and explain that you need . large print or Braille, please call . 1-800-743-5000. help with your Medical Baseline Program application. 3 . …

Share them with your qualified medical practitioner and explain that you need help with your application. Three: Your medical practitioner will use your unique code to complete their portion. Four: Once your application is processed, you’ll be enrolled in the program. Certain electric rate plans may be excluded.Medical Baseline program customers who are enrolled in an income-qualified program, such as the California Alternate Rates for Energy (CARE) or Family Electric Rate Assistance (FERA) programs, and live in a high fire risk area are also now eligible for the Critical Care Backup Battery Program, which provides a free, portable …Medical Baseline program customers who are enrolled in an income-qualified program, such as the California Alternate Rates for Energy (CARE) or Family Electric Rate Assistance (FERA) programs, and live in a high fire risk area are also now eligible for the Critical Care Backup Battery Program, which provides a free, portable …Medical Baseline Allowance Application. (Used for Medical Baseline Enrollment and Re-Certification) PART I: TO BE COMPLETED BY CUSTOMER (please print) FOR …Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable. MEDICAL BASELINE ALLOWANCE. On average this form takes 16 minutes to complete. The MEDICAL BASELINE ALLOWANCE form is 16 pages long …MAIL APPLICATION TO: Southern California Edison Company Medical Baseline Department P.O. Box 9527 Azusa, CA 91702-9954 Customer’s Name (as it appears on your bill): ... The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/19. Qualifying Medical-Based Need ; Help Someone Avoid Disruption of Service ; Assistance for Those with Limited Vision; Referrals to Social Services Agencies ; One-time Assistance Bill Assistance ; Low Income Federal Financial Aid for Qualifying Customers ; Savings Center. Overview; Tips. Home Electrification; Take a Home Energy Survey ...

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Once you’ve completed an application and obtained verification from your licensed physician, surgeon or osteopath, an additional monthly medical allowance of 25 therms will be provided at the lowest (baseline) rate for hemiplegic / paraplegic / quadriplegic persons, multiple sclerosis / scleroderma patients and persons who are being treated for a life-threatening illness and have a ...Medical Baseline program customers who are enrolled in an income-qualified program, such as the California Alternate Rates for Energy (CARE) or Family Electric Rate Assistance (FERA) programs, and live in a high fire risk area are also now eligible for the Critical Care Backup Battery Program, which provides a free, portable …Key Takeaways: The SCE Medical Baseline program offers an additional 16.5 kWh of electricity per day for eligible households.; Eligibility criteria include the regular use of electrically powered medical or life support equipment. Application can be done online or by downloading and mailing the SCE Medical Baseline Allowance form.; Participating … Mail the completed application to: SoCalGas Medical Baseline Allowance Program. M. L. GT19A1. P.O. Box 513249 Los Angeles, CA 90051-1249 Once we receive your application, we will review the information. If you qualify, you will see the additional Medical Baseline Allowance on your bill. Please allow one full billing cycle for the change. 한국어: 1-800-427-0471. Tiếng Việt: 1-800-427-0478. For other languages: 1-888-427-1345. Hearing impaired (TDD): 1-800-252-0259. Eligibility requirements apply; see the program conditions for details. The Medical Baseline Allowance program provides additional natural gas at the lowest baseline rate for individuals with a serious health ... The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day, which is in addition to to your daily Standard Baseline Allocation. MORENO VALLEY UTILITY MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED …To apply for the medical lifeline . allowance, please print: Customer’s full name . Patient’s full name . Patient’s Social Security Number . Patient’s Drivers License Number . Patient’s relationship to customer . Patient’s address . City State Zip . Daytime telephone number MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) I certify that the medical condition and needs of my patient (please print): Last name _____First name _____ Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1.The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts.For many aspiring medical professionals, getting into medical school is the first step towards achieving their career goals. However, the application process can be overwhelming an...Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME ….

The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts.Medical Baseline is a financial assistance program for eligible residential customers who have additional energy needs due to certain qualifying medical conditions. The Medical Baseline Program will increase a customer's baseline allotment, allowing them to use more energy at the lowest price for their chosen rate. If you are on a rate program ...The Standard Medical Baseline Allowance provides extra energy at the lowest price. Medical baseline allowances are added to your standard rate plan Baseline allocation. For electricity, it is 16.438 kWh per day (500 kWh per month). This additional amount is equal to the daily consumption of an average electric household.Share them with your qualified medical practitioner and explain that you need help with your application. Three: Your medical practitioner will use your unique code to complete their portion. Four: Once your application is processed, you’ll be enrolled in the program. Certain electric rate plans may be excluded. Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification)::::: I understand that: 1 If the doctor certifies the resident’s medical condition is permanent, SDG&E will require completion of a form self-certifying resident’s continued eligibility for the Medical Baseline Allowance every ... Medical Baseline Allowance. If you or someone in your household uses electrically powered medical equipment, you may qualify for the Medical Baseline Allowance. This funding provides for an additional 16.5 kilowatt-hours (kWh) of electricity per day at the lowest baseline rate to help offset the cost of operating your medical equipment. Learn …Fax Mail Email. 1-866-997-9427 PO Box 1498, Victorville, CA 92393. [email protected]. Southwest Gas Corporation does not guarantee the privacy or security of faxed or electronic mail documents. By sending or requesting information be sent via facsimile or electronic mail, you are agreeing to accept any associated risk. promptly notify SCE if the qualified resident moves or no longer requires the Medical Baseline Allowance. The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs ... By Your Bill. Add a monthly fixed donation amount to your bill (ie. $5) or make a one-time donation in any amount. Call 1-800-205-8596. Expose as Block. No. Add Horizontal line. Off. Southern California Edison partners with the United Way to help qualified customers pay their electric bills – apply or donate today. Medical baseline allowance application, MEDICAL BASELINE ALLOWANCE APPLICATION The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts., MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer …, your paper application to: PG&E Billing Center Medical Baseline, P.O. Box 8329, Stockton, CA 95208. STEP 4 Signature I certify the above information is correct. I also certify the Medical Baseline resident lives full-time at this address and requires or continues to require the Medical Baseline program., The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily . ... MAIL APPLICATION TO: SoCalGas. Medical Baseline Allowance Program . M. L. GT19A1 P.O. Box 513249 Los Angeles, CA 90051-1249 Fax: 213-244-4665. Email: [email protected] ., For gas, it is 0.82192 therms per day (approx. 25 therms per month), an additional amount equal to three-quarters of the daily consumption of an average gas household. If these Medical Baseline allowances do not meet your medical energy needs, please contact PG&E at 1-800-743-5000. More information about the Medical Baseline program can be ..., Once you’ve completed an application and obtained verification from your licensed physician, surgeon or osteopath, an additional monthly medical allowance of 25 therms will be provided at the lowest (baseline) rate for hemiplegic / paraplegic / quadriplegic persons, multiple sclerosis / scleroderma patients and persons who are being treated for a life …, To apply for the Medical Baseline Allowance, your service must already be established. As a new customer, you can go online and follow these steps: Go to START OR STOP SERVICE and select New to PG&E. Provide your name and identification. You can use your Social Security or Tax ID number, or an alternate form of identification such as a driver's ..., Calculate your Baseline Allowance for a billing cycle: Your daily amount of energy. x. The number of billing days. = Your Baseline Allowance for a billing cycle. Find the daily amount of energy allotted for your Baseline Allowance in the table below. Find the number of billing days on page 3 of your energy statement . View a sample statement. , Date Received: Medical Baseline Allocation: Electric unit(s) Gas unit(s) Recertification: c Self-certify every two years c Self-certify annually; medical provider’s certification every two years MAIL APPLICATION TO: SoCalGas Medical Baseline Allowance Program M. L. GT19A1 P.O. Box 513249 Los Angeles, CA 90051-1249 Fax: 213-244-4665 , To apply for the Medical Baseline Allowance program, fill out the customer section (Part 1) of the attached application. Next, have the patient’s qualifying medical professional complete and sign the remaining section (Part 2). Review the application to make sure it is complete and return it to: Southern California Edison Medical Baseline ..., The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts., The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12., 1. Applying online on the dedicated Medical Baseline websites,or 2. Printing an application from the utilities’webpages and mailing it in, or 3. Calling the utility Customer Service numbers to request an application bemailed • Caretakers, family members or agents providing support to qualifying individuals can also assist, Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1., The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427 …, The Medical Baseline Program, also known as Medical Baseline Allowance, is an assistance program for residential customers who depend on power for certain medical …, You may qualify for the Medical Baseline Allowance even if your landlord bills you for your natural gas. You can apply online or by mail, email, or fax. Visit their website to access the application. In addition to listed languages, services are also offered in Mandarin and Cantonese. Spanish: 800-342-4545 Mandarin: 800-427-1429 Cantonese: 800 ..., Customer Signature: Date: ICAL DO TOR (M.D.) OR DOCTOR. PART 1 TO BE COMPLETED BY CUSTOMER (please print) (11-0700.v2.01/16 BPDI) Page 2of 28800-1000-400-0013. MEDICAL BASELINE ALLOWANCE APPLICATION Used for Medical Baseline Enrollment and Re-Certification. OF OSTEOPATHY (D.O.). I certify that the …, The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts. , You still have the same solar plan options. With medical baseline and an address in tier 2 or 3 fire zone per CPUC map one qualifies for a very generous category of CA SGIP a battery rebate. If you’ve experienced documented PSPS events that can qualify you if you’re not in a fire zone. You can look up your meter number to check., You can obtain an application for this program by calling BVES at 1-800-808-BVES(2837). A certification from a doctor, physician assistant, or nurse ..., If you are on an electric rate without a baseline, you may be eligible to receive a flat 12% D-MEDICAL discount. If these Medical Baseline allowances do not meet your medical energy needs, please contact PG&E at 1-800-743-5000. More information about the Medical Baseline program can be found at pge.com/medicalbaseline., Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1., MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) I certify that the medical condition and needs of my patient (please print): Last name _____First name _____ , for additional electricity at the baseline rate. Customers on the TOU-D PRIME rate may qualify for a flat 11% discount. For further information, you can visit sce.com or contact SCE by dialing 1-800-655-4555. How do I apply for MBL? You can apply to the Medical Baseline Allowance Program online, by mail, or with our assistance by phone., The Medical Baseline Program, also known as Medical Baseline Allowance, is an assistance program for residential customers who depend on power for certain medical …, agree to promptly notify SCE if the qualified resident moves or no longer requires the Medical Baseline Allowance. The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If you are on an electric rate without a ... , The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily . ... MAIL APPLICATION TO: SoCalGas. Medical Baseline Allowance Program . M. L. GT19A1 P.O. Box 513249 Los Angeles, CA 90051-1249 Fax: 213-244-4665. Email: [email protected] ., Re-certification is required to verify that the Medical Baseline customer still needs extra PSPS notifications and additional allotment of energy due to their ongoing medical condition. Visit the Apply for the Medical Baseline Program page for more details, eligibility requirements and application directions. Self-Certification is required for ..., Medical Baseline Allowance Program Overview. The Medical Baseline Allowance Program provides an additional amount of gas and electricity at the lowest rates for residential customers. It is not a discount or a rebate. Anyone who uses certain medical devices or needs space heating or air conditioning because of a medical condition may qualify. , Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME, MEDICAL BASELINE ALLOWANCE APPLICATION . Patient’s Last Name: First Name: PART 2: TO BE COMPLETED BY A MEDICAL PROVIDER (LICENSED MEDICAL DOCTOR [M.D.], DOCTOR OF OSTEOPATHY [D.O.], NURSE PRACTITIONER [N.P.] OR PHYSICIAN’S ASSISTANT [P.A.]) I certify that the medical condition and needs of my …, Once they sign off on the application, the baseline allowance will be added to your account. You can also print out a PDF copy of the application and complete it by hand. It will to be signed by a medical practitioner to certify the medical condition. Mail the completed and signed application form to: PG&E Attention: Medical Baseline P.O. Box …