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Pge Medical Baseline 2018
Baseline Allowance Self-Certification Request Form
STEP 1 Account and Customer Information (please print)
I understand that:
PG&E CUSTOMER ACCOUNT NO
1. If the doctor certifies the resident’s medical
condition is permanent, PG&E will require
completion of a form self-certifying
continued resident’s eligibility for Medical
Baseline every two years.
CUSTOMER NAME (as it appears on PG&E bill)
MEDICAL BASELINE RESIDENT’S NAME (if different)
SERVICE ADDRESS
CITY
APT #
STATE
CUSTOMER...
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