Medical Baseline Program Application—Part A
(To be completed by customer.)
For Medical Baseline Program Enrollment and Recertification
STEP 1 Account and Customer Information (Please print.) I understand and agree that:
1. If the qualified medical practitioner certifies the
resident’s medical condition is permanent, PG&E
PG&E CUSTOMER ACCOUNT NO.
requires completion of a form every two years
self-certifying the resident’s continued eligibility for
the Medical Baseline Program.
2. If the qualified medical practitioner certifies the
CUSTOMER NAME (as it appears on PG&E bill)
resident’s medical condition is not permanent, PG&E
requires completion of a form every year self-certifying
the resident’s continued eligibility for the Medical
MEDICAL BASELINE RESIDENT’S NAME (if different than customer name)
Baseline Program and completion of a new application
including a qualified medical practitioner’s certification
every two years.
SERVICE ADDRESS APT #
3. Residents with a vision disability may contact PG&E to
request special notification when notices are sent for
either recertification (completion of a new application
CITY STATE ZIP CODE
including a qualified medical practitioner certification)
or self-certification.
CUSTOMER MAILING ADDRESS (if different than service address) APT #
4. PG&E cannot guarantee uninterrupted gas and
electric service. I am responsible for making alternate
arrangements in the event of a gas or an electric
outage.
CITY STATE ZIP CODE
5. Both Part A and Part B of this form must be completed
and submitted to PG&E, online or by mail, prior to
HOME PHONE # WORK PHONE #
PG&E processing the application.
6. Customers may also benefit from energy savings
STEP 2 For customers billed by someone other than PG&E
programs such as Energy Upgrade California
®
Home
Upgrade. The Energy Savings Assistance Program for
income-qualified customers, provides improvements
at no charge. For more information, please visit
pge.com/saveenergy.
NAME OF MOBILE HOME OR APARTMENT COMPLEX
7. PG&E may share my contact information with
organizations such as state and local emergency
first response agencies, so that they can provide
COMPLEX ADDRESS
assistance to PG&E and to me personally during an
extended outage to support my safety and well-being.
8. The standard Medical Baseline allowance provides
COMPLEX MANAGER’S NAME COMPLEX PHONE #
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
TENANT’S NAME TENANT’S PHONE #
day (approx. 500 kWh per month), an additional amount
equal to the daily consumption of an average electric
STEP 3 Contact preferences for outages or other Medical Baseline
communications
(Check all that apply.)
household. 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
Please make sure PG&E has your correct contact preferences so we can reach you
in advance of a planned public safety power shutoff (PSPS) or other situations that
allowances do not meet your medical energy needs,
please contact PG&E at 1-800-743-5000. More
may result in an outage. In certain situations, we may also send a letter. All contact
methods will be used during a PSPS event.
information about the Medical Baseline Program can
be found at pge.com/medicalbaseline.
CONTACT PREFERENCES
STEP 4 Signature
Call phone number 1:
I certify the above information is correct. I also certify the
Medical Baseline resident lives full-time at this address
Call phone number 2:
and requires the Medical Baseline Program. I agree to allow
Text mobile number 1:
PG&E to verify this information. I also agree to notify PG&E
promptly if the qualified resident moves or the resident no
Text mobile number 2:
longer needs the Medical Baseline Program.
Email 1:
SIGN
Email 2:
CUSTOMER SIGNATURE
Contact by TTY at phone number:
Automated Document, Preliminary Statement, Part A
62-3481-A April 2020 CMB-0420-2187
DATE
FOR INTERNAL USE ONLY:
