Fillable MEDICAL BASELINE ALLOWANCE (SoCalGas)

Fill Online, Printable, Fillable, Blank MEDICAL BASELINE ALLOWANCE (SoCalGas) Form

Use Fill to complete blank online SOCALGAS 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 (SoCalGas)

On average this form takes 11 minutes to complete

The MEDICAL BASELINE ALLOWANCE (SoCalGas) form is 3 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your SoCalGas forms online.

BROWSE SOCALGAS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
(Continued)
WHAT IS MEDICAL BASELINE ALLOWANCE?
The Medical Baseline Allowance program provides
additional natural gas for SoCalGas
®
customers with
certain medical conditions to help keep the house
warm. 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. Eligibility is NOT
based on income.
WHAT IF I PAY MY LANDLORD
FOR MY NATURAL GAS?
You may qualify for the Medical Baseline Allowance
even if your landlord bills you for your natural gas.
The landlord will reflect the allowance on your billing
statement.
HOW DO I APPLY?
To apply, complete Part 1 of the attached application.
Next, have a medical provider complete Part 2 of the
application, certifying the need for additional heat due
to the medical condition. Medical providers include
licensed medical doctors [M.D.], doctors of osteopathy
[D.O.], nurse practitioners [N.P.] or physician’s assistants
[P.A.]). We accept e-signatures from medical providers.
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.
WHAT IF I NEED ASSISTANCE?
If you need assistance in a language other than English
or Spanish, please call our Language Interpreter
Service Line at 888-427-1345.
Hearing impaired customers who are unable to use a
conventional telephone can call us toll free at 800-252-
0259 (available in English and Spanish only).
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.
Please keep a completed copy of the application for
your records.
MEDICAL BASELINE ALLOWANCE
INFORMATION & APPLICATION
1-800-427-1429
1-800-427-0478
1-800-427-0471
1-800-427-1420
©2020 Southern California Gas Company. All copyright and trademark rights reserved. FORM 4859E N20E00227A 1020
(Continued)
APPLICATION FOR ENROLLMENT
AND RE-CERTIFICATION
PART 1: TO BE COMPLETED BY CUSTOMER (PLEASE PRINT)
SoCalGas Customer Account No:
Customer Name (as it appears on your bill):
Medical Baseline Resident’s Name (if different):
Service Address:
Customer Mailing Address (if different):
Home Phone: ( ) Alternate Phone: ( )
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: ( )
I UNDERSTAND THAT:
1 If 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.
2 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.
3 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.
4 SoCalGas cannot guarantee uninterrupted natural gas service, and the resident is responsible for making alternate
arrangements in the event of a natural gas outage.
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?
Select only one:
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:
Customer Signature:
Date:
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).
MEDICAL BASELINE ALLOWANCE APPLICATION
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 (please print):
Patient’s Last Name: First Name:
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.
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICAL BASELINE ALLOWANCE (SoCalGas)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document