Fillable MEDICAL BASELINE ALLOWANCE

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MEDICAL BASELINE ALLOWANCE

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PAGE 1 OF 10
MEDICAL BASELINE ALLOWANCE
INFORMATION & APPLICATION
What is Medical Baseline Allowance?
The Medical Baseline Allowance program provides
additional natural gas for people with certain medical
conditions. It is not a discount or rebate. Customers on
this program will receive 0.822 additional therms per
day, billed at our lowest baseline rate.
Qualifications
To qualify, you or a full-time resident of your home
must require additional heat due to a qualifying medical
condition. For example, you may qualify if a resident
of your home has paraplegia, quadriplegia, hemiplegia,
multiple sclerosis, scleroderma, a compromised immune
system or a life threatening illness.
What if I pay my landlord for my natural gas?
You may qualify for Medical Baseline Allowance even
if your landlord bills you for your natural gas. The
landlord will reflect the allowance on your billing
statement.
PAGE 2 OF 10
How do I apply?
To apply, complete Part 1 of the attached application.
Next, have a medical provider (licensed medical doctor
[M.D.], doctor of osteopathy [D.O.], nurse practitioner
[N.P.] or physician’s assistant [P.A.]) 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:
SoCalGas
Medical Baseline
Allowance Program
M. L. GT19A1
P.O. Box 513249
Los Angeles, CA 90051-1249
Fax: 213-244-4665
Once we receive your application, we will review the
information. If you qualify, you will see the additional
allowance on your bill. Please allow one full billing cycle
for the change. If you move, you must notify SoCalGas
®
so that your allowance can be transferred to your new
address. Providing assistance to customers with special
needs is just one way we strive to keep natural gas
affordable.
MEDICAL BASELINE ALLOWANCE INFORMATION
PAGE 3 OF 10
For more information
Please visit socalgas.com/Medical
or call 1-800-427-2200.
Para una solicitud de Asignación Médica Inicial en
español, por favor llame al 1-800-342-4545.
If you need assistance after hours in a language other
than English or Spanish, please call our Language
Interpreter Service Line at 1-888-427-1345.
1-800-427-1429
1-800-427-0478
1-800-427-0471
1-800-427-1420
Hearing impaired customers who are unable to use a
conventional telephone can call us toll free at
1-800-252-0259 (available in English and Spanish only).
Please keep a completed copy of the application for
your records.
©2020 Southern California Gas Company. All copyright and trademark rights reserved. FORM 4859E LRG FNT N20E0132A 0420
socalgas.com
1 (800) 427-2200
MEDICAL BASELINE ALLOWANCE INFORMATION
PAGE 4 OF 10
APPLICATION FOR ENROLLMENT
AND RE-CERTIFICATION
PART 1: To be completed by customer (please print)
ACCOUNT NUMBER
(Please provide your SoCalGas Customer account number)
CUSTOMER NAME (First and last as it appears on your bill)
MEDICAL BASELINE RESIDENT’S NAME (if different)
SERVICE ADDRESS APT/SPACE #
CITY
CUSTOMER MAILING ADDRESS (if different)
CITY
PRIMARY PHONE
ALTERNATE PHONE
- -
- -
(Continued next page)
PAGE 5 OF 10
MEDICAL BASELINE ALLOWANCE APPLICATION
(Continued next page)
For customers billed by someone other than SoCalGas:
NAME OF MOBILE HOME OR APARTMENT COMPLEX
COMPLEX ADDRESS
COMPLEX MANAGER’S NAME
COMPLEX PHONE
NAME OF TENANT
TENANT’S PHONE
- -
- -
PAGE 6 OF 10
I UNDERSTAND THAT:
1If the medical provider certifies that the resident’s
medical condition is permanent, SoCalGas will require
completion of a form self-certifying continued resident’s
eligibility for Medical Baseline Allowance every two years.
If the medical provider certifies that the resident’s
medical condition is not permanent, SoCalGas will require
completion of a form self-certifying continued resident’s
eligibility for Medical Baseline Allowance each year and
completion of a new application with a medical provider’s
certification every two years.
If the resident has a vision disability, the resident may
contact SoCalGas to request special notification when
either re-certification (to complete a new application with
a medical provider’s certification) or self-certification forms
are mailed.
SoCalGas cannot guarantee uninterrupted natural gas
service, and the resident is responsible for making
alternate arrangements in the event of a natural gas
outage.
MEDICAL BASELINE ALLOWANCE APPLICATION
(Continued next page)
PAGE 7 OF 10
SIGNATURE
:
DATE:
/ /
X
I certify that the above information is correct. I also certify the
Medical Baseline Allowance resident lives full-time
at this address, and requires or continues to require the
medical baseline allowance. I agree to allow SoCalGas
to verify this information. I also agree to promptly notify
SoCalGas if the qualified resident moves or medical
baseline allowance is no longer needed by the resident.
How would you like to be contacted in case of a planned
or rotating outage?
c
Call me at the number below
c Send me a text message at the number below
c Contact me by TDD/TTY at the number below
c Email me at the address below
NUMBER OR EMAIL:
MEDICAL BASELINE ALLOWANCE APPLICATION
(Continued next page)
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. Hearing impaired
customers who are unable to use a conventional telephone can call us toll
free at 1-800-252-0259 (available in English and Spanish only).
PAGE 8 OF 10
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 patient
Patient’s Last Name (please print):
Patient’s First Name (please print):
1. Requires use of a life-support device
*
(check one)
c Yes c No
The following life-support device(s) is(are) used in the above-named
patient’s home:
Device:
c Electricity c Natural gas
Device:
c Electricity c Natural gas
Device:
c Electricity c Natural gas
*Qualifying life-support equipment is any device which uses
mechanical or artificial means to sustain, restore, or supplant a vital
function. The device must run on natural gas supplied by SoCalGas.
Devices used for therapy rather than life-support, such as pools and
spas, do not qualify.
MEDICAL BASELINE ALLOWANCE APPLICATION
(Continued next page)
MEDICAL BASELINE ALLOWANCE APPLICATION
PAGE 9 OF 10
(Continued next page)
X
2. Requires heating and cooling:
Standard Medical Baseline Allowances are available for
heating if patient is paraplegic, quadriplegic, hemiplegic, has
multiple sclerosis or scleroderma. Standard Medical Baseline
Allowances are also available if patient has a compromised
immune system, life threatening illness, or any other
condition for which additional heating is medically
necessary to sustain the person’s life or prevent
deterioration of the person’s medical condition.
Requires standard Medical Baseline Allowance for heating:
(check one) c Yes c No
3. I certify that the life-support device(s) and/or
additional heating will be required for approximately:
(check one) c No. of Years or c Permanently
MEDICAL PROVIDER’S NAME:
PHONE NO.:
- -
OFFICE ADDRESS:
M.D./D.O./N.P./P.A. STATE LICENSE OR MILITARY LICENSE NUMBER:
MEDICAL PROVIDER’S SIGNATURE:
DATE:
/ /
FOR SOCALGAS USE ONLY
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
MEDICAL BASELINE ALLOWANCE APPLICATION
PAGE 10 OF 10
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MEDICAL BASELINE ALLOWANCE

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Completed 7 November 2020

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