Medical Baseline Allowance Self Certification - Southern California ...

Southern California Edison Original Cal. PUC Sheet No. 31681-E
Rosemead, California Cancelling Cal. PUC Sheet No.
Sheet 1
MEDICAL BASELINE ALLOWANCE SELF CERTIFICATION
Form 14-747 SC
(To be inserted by utility) Issued by (To be inserted by Cal. PUC)
Advice 1635-E John R. Fielder Date Filed Jul 10, 2002
Decision 02-04-026 Senior Vice President Effective Jul 10, 2002
1C12
Resolution

MEDICAL BASELINE ALLOWANCE SELF-CERTIFICATION
TO BE COMPLETED BY CUSTOMER (please print)
SCE 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 (____)_________________________ Work Phone (____)________________________________
For Customers Billed by Someone Other Than SCE:
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 doctor certifies the resident’s medical condition is permanent, SCE will require completion of a form
self-certifying continued resident eligibility for Medical Baseline every two years.
2. If the doctor certifies the resident’s medical condition is not permanent, SCE will require completion of a form
self-certifying continued resident eligibility for Medical Baseline each year and completion of a new
application with a doctor’s certification every two years.
3. If the resident has a vision disability, I may contact SCE to request special notification when re-certification
forms (to complete a new application with a doctor’s certification) are mailed.
4. SCE cannot guarantee uninterrupted electric service and I am responsible for making alternate arrangements in
the event of an electric outage.
I certify that the above information is correct. I also certify that the Medical Baseline resident lives full-time at this
address, and requires or continues to require the Medical Baseline Allowance. I agree to allow SCE to verify this
information. I also agree to promptly notify SCE if the qualified resident moves or Medical Baseline
Allowance is no longer needed by the resident.
Customer Signature __________________________________________ Date: _________________
The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day, which is in addition to your
daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-
447-6620 to discuss additional amounts.
FOR SCE USE ONLY Date Received: ______________
Medical Baseline Allocation: ______ Electric unit(s)
Re-certification: ( ) Self-certify every 2 years ( ) Self-certify annually; Doctor’s certification every 2 years
Form 14-747 SC
Mail application to
Southern California Edison Company Medical Baseline
P.O. BOX 6400 Rancho Cucamonga CA 91729-9824