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Medical Baseline Application

San Diego Gas & Electric is dedicated to providing safe and reliable energy to those who depend on life support equipment or have special medical conditions. The Medical Baseline Allowance Program helps customers save every month on their energy bill. Application may take up to 30 days to process. If you have more than qualifying patient in the same household, please fill out a separate application for each person.

Account Information

Date

SDG&E Account Number

Account First Name

Account Last Name

Service Address

City/Town

ZIP/Postal Code

Mailing Address if different than service address)

City/Town

ZIP/Postal Code

Patient Information (If you have more than one qualifying patient in the same household, please fill out a separate application for each person.)

Patient First Name

Patient Middle Initial

Patient Last Name

Preferred Language

Home Phone Number

Mobile Phone Number

Email Address

Email Address

Associated Phone Number

Qualifying Medical Devices

	Select all that apply.
	Aerosol Tents
	Air Mattress/Hospital Beds
	Apnea Monitors
	Breather Machines (IPPB)
	Compressors/Concentrators
	Continuous Positive Airway Pressure (CPAP)
	Dialysis Machines
	Electrostatic Nebulizers
	Electric Nerve Stimulators
	Hemodialysis Machines
	Infusion Pumps
	Inhalation Pulmonary Pressure
	Iron Lungs
	Left Ventricular Assist Devices (LVAD)
	Lympha Press Devices
	Motorized Wheelchairs
	Oxygen Generators
	Pacemaker Monitor/Defibrillator
	Pressure Pads
	Pressure Pumps
	Pulse Oximeters/Monitors (must be used with other medical devices, cannot be powered by battery)
	Respirators (all types)
	Suction Machines
	Total Artificial Heart (TAH-t)
	Ultrasonic Nebulizers
	The Vest/Airway Clearance System

The medical device is required for life support?

Yes

No

How long can the patient survive without using life support equipment? Check one.

2 Hours or Less

More than 2 Hours

Note: While we do our best to avoid outages, we cannot guarantee that the power will always be on. Outages happen. SDG&E will attempt to notify the patient in advance of a state-directed power outage. However, if the patient requires life support equipment, he/she should make arrangements for a backup power supply in case of an outage.

Heating and Cooling Needs

Patient requires the Standard Medical Baseline Allowance for heating?

Yes

No

Patient requires the Standard Medical Baseline Allowance for cooling?

Yes

No

I certify that the medical device(s) and/or additional heating or cooling will be required for approximately:

Select one:

Select this option to designate the number of years required.

Permanently

Estimate of Number of Years Required

Note: While we do our best to avoid outages, we cannot guarantee that the power will always be on. Outages happen. SDG&E will attempt to notify the patient in advance of a state-directed power outage. However, if the patient requires life support equipment, he/she should make arrangements for a backup power supply in case of an outage.

For Customers Billed By Someone Other Than SDG&E

Name of Mobile Home or Apartment Complex

Address

Unit/Space

City/Town

ZIP/Postal Code

Complex Manager's Name

Complex Phone Number

Name of Tenant

Tenant's Phone Number

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Terms and Conditions

Certification

Yes, I certify.

I certify that the above information is correct. I also certify that the qualifying resident lives full-time at this address and requires or continues to require the Medical Baseline Allowance. I agree to allow SDG&E to verify this information. I also agree to promptly notify SDG&E if the qualified resident moves or the Medical Baseline Allowance is no longer needed by the resident. By signing below, I authorize SDG&E to share my customer information with other utilities and/or their agents to enable them to enroll me in other utility assistance programs.

I also authorize SDG&E to share my information regarding my participation in SDG&E’s Medical Baseline Allowance Program, including, without limitation, my name, address, contact information, circuit data, Medical Baseline Allowance Program enrollment status and medical equipment needs as described in this form if requested by emergency services professionals and agencies at the city, county, state and federal level for the purposes of managing de-energizations and to allow such parties to plan for and manage emergency situations.