Due to COVID-19 shelter-in-place requirements and changing medical practitioner priorities, SIGNATURE BY A QUALIFIED MEDICAL PRACTITIONER IS NOT REQUIRED to apply but may be required to remain on the program beyond one year.

Please complete all required fields and click SUBMIT to ensure your application is received.

Your contact information

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MEDICAL BASELINE RESIDENT’S NAME (if different than customer name)

Enter a full address within PG&E’s service territory.

Enter a full address.

Enter the number associated with your account, if possible.

Enter the number associated with your account, if possible.

Customers billed by someone other than PG&E

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Enter a full address within PG&E’s electric service territory, then hit ENTER.

Contact preferences for outages or other Medical Baseline communications

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 may result in an outage. In certain situations, we may also send a letter. All contact methods will be used during a PSPS event.

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The Medical Baseline Resident condition and needs include:

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REQUIRES USE OF LIFE SUPPORT DEVICE(S)? (CHECK ONE.) *
The following life-support device(s) is/are used by the Medical Baseline Resident:

 

A qualifying life support device is any medical device used to sustain life or relied upon for mobility. This device must run on gas or electricity delivered by PG&E. It includes, but is not limited to, respirators (oxygen concentrators), iron lungs, hemodialysis machines, suction machines, electric nerve stimulators, pressure pads and pumps, aerosol tents, electrostatic and ultrasonic nebulizers, compressors, IPPB machines, kidney dialysis machines and motorized wheelchairs. Devices used for therapy rather than life support do not qualify.

Requires heating and/or cooling:

Standard Medical Baseline allowances are available for heating and/or cooling if the Medical Baseline Resident is a paraplegic, quadriplegic, hemiplegic, has multiple sclerosis or scleroderma. Standard Medical Baseline allowances are also available if the Medical Baseline Resident has a compromised immune system, life-threatening illness, or any other condition for which additional heating or cooling is medically necessary to sustain the patient’s life or prevent deterioration of the patient’s medical condition.

Terms and Conditions

  1. If the qualified medical practitioner certifies the resident’s medical condition is permanent, PG&E 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 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 Baseline Program and completion of a new application including a qualified medical practitioner’s certification every two years.

  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 including a qualified medical practitioner certification) or self-certification.

  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.

  5. All fields marked as “required” on this form must be filled out and submitted to PG&E, prior to the application being processed.

  6. Customers may also benefit from energy savings 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.

  7. PG&E may share my contact information with organizations such as state and local emergency first response agencies, so that they can provide 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 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 (approx. 500 kWh per month), an additional amount equal to the daily consumption of an average electric 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 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.

I certify the above information is correct. I also certify the Medical Baseline resident lives full-time at this address and requires the Medical Baseline Program. I agree to allow PG&E to verify this information. I also agree to notify PG&E promptly if the qualified resident moves or the resident no longer needs the Medical Baseline Program.

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