Medical baseline allowance application

Medical baseline allowance application. Complete Medical Baseline Allowance BApplicationb - Southern California Edison online with US Legal Forms. Easily fill out PDF blank, ... California (U 338E) Cancelling Revised Revised Cal. PUC Sheet No. Cal. PUC Sheet No. 51882E 48140E Sheet 1 MEDICAL BASELINE ALLOWANCE APPLICATION Form 14746 (To. How It Works. Open form …

To apply for the Medical Baseline Allowance program, fill out the customer section (Part 1) of the attached application. Next, have the patient’s qualifying medical professional complete and sign the remaining section (Part 2). Review the application

MEDICAL BASELINE ALLOWANCE APPLICATION The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts.Medical Baseline is a financial assistance program for eligible residential customers who have additional energy needs due to certain qualifying medical conditions. The Medical Baseline Program will increase a customer's baseline allotment, allowing them to use more energy at the lowest price for their chosen rate. If you are on a rate program ...MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer …What is the Medical Baseline Allowance Program? The Medical Baseline Allowance Program provides an additional amount of gas and electricity at the lowest rates for residential customers. It is not a discount or rebate. In addition to your standard baseline allocation, the allowance received with the program is 16.5 kWh of electricity per day orApply Now . Medical Baseline Allowance Application Form; Submit completed application: By Email: [email protected] By Fax: 877.349.3870 By Mail: MVU Payment Processing 380 N. San Jacinto St. Hemet, CA 92543 In Person: 14331 Frederick St. Suite 2 Moreno Valley Map LinkThe Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12. 2. If the doctor certifies the resident’s medical condition is not permanent, PG&E will require completion of a resident’s 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 PG&E to request special ...

The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts.Nov 10, 2015 ... Hawkes couldn't estimate how much money he's saved through the Southern California Edison program, known as a medical baseline allowance.According to MedicineNet, NPO is a medical abbreviation that means nil per os, or nothing by mouth. It means that a patient isn’t allowed any food or drink for medical reasons, as ...MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) I certify that the medical condition and needs of my patient (please print): Last name _____First name _____You may qualify for the Medical Baseline Allowance even if your landlord bills you for your natural gas. You can apply online or by mail, email, or fax. Visit their website to access the application. In addition to listed languages, services are also offered in Mandarin and Cantonese. Spanish: 800-342-4545 Mandarin: 800-427-1429 Cantonese: 800 ...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 no longer requires the Medical Baseline Allowance. The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of ...How to Apply. Apply Online. Download Medical Baseline Allowance Application. Download Medical Baseline Allowance Application (Spanish) To learn more, contact your local Liberty office at 1-800-782-2506 (electric customers only).

How do I recertify for the Medical Baseline Program? If you are an active Medical Baseline customer with a non-permanent medical condition and need to recertify for continued eligibility, please visit the Apply for the Medical Baseline Program page and follow the steps to complete the application process. SUBMIT FEEDBACK. If you are an …Once you’ve completed an application and obtained verification from your licensed physician, surgeon or osteopath, an additional monthly medical allowance of 25 therms will be provided at the lowest (baseline) rate for hemiplegic / paraplegic / quadriplegic persons, multiple sclerosis / scleroderma patients and persons who are being treated for a life-threatening illness and have a ...According to MedicineNet, NPO is a medical abbreviation that means nil per os, or nothing by mouth. It means that a patient isn’t allowed any food or drink for medical reasons, as ...If you are on an electric rate without a baseline, you may be eligible to receive a flat 12% D-MEDICAL discount. 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.Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME2. If the doctor certifies the resident’s medical condition is not permanent, PG&E will require completion of a resident’s 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 PG&E to request special ...

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Become a member of the Psych Central medical network! Allow clients to find you with unique custom filters, including: Psych Central’s comprehensive medical integrity team will vet... Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1. The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts.You can complete the Medical Baseline application online by visiting our Apply for the Medical Baseline Program page. After completing the application, you will be emailed a …According to the Centers for Disease Control and Prevention, baseline assessment, or baseline testing, is a medical evaluation used by professionals to obtain general information a... Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME

A HIPPA medical release form is signed to allow other individuals or organizations to have access to a patient’s personal medical records, medical history and health information. A...To apply for the Medical Baseline Allowance, your service must already be established. As a new customer, you can go online and follow these steps: Go to START OR STOP SERVICE and select New to PG&E. Provide your name and identification. You can use your Social Security or Tax ID number, or an alternate form of identification such as a driver's ...of a form self-certifying continued resident’s eligibility for Medical Baseline Allowance each year and completion of a new application with a medical provider’s certification every two years. 3 If the resident has a vision disability, the resident may contact SoCalGas to request special notification when either re-certification (to ...Yes. Medical Baseline Allotment and California Alternate Rates for Energy Program (CARE) are two separate programs. Medical Baseline Allotment is not based on income. Customers may qualify for both programs. If you qualify for the CARE benefit, you receive a discount on gas and electric rates. If you may qualify for Medical Baseline Allotment ...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 (500 kWh per month). This additional amount is equal to the daily consumption of an average electric household. MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) I certify that the medical condition and needs of my patient (please print): Last name _____First name _____ To apply for the Medical Baseline Allowance program, fill out the customer section (Part 1) of the attached application. Next, have the patient’s qualifying medical professional complete and sign the remaining section (Part 2). Review the application to make sure it is complete and return it to: Southern California Edison Medical Baseline ...The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily . ... MAIL APPLICATION TO: SoCalGas. Medical Baseline Allowance Program . M. L. GT19A1 P.O. Box 513249 Los Angeles, CA 90051-1249 Fax: 213-244-4665. Email: [email protected] .The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If you are on an electric rate without a baseline, you may be eligibleMedical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAMEEthics involves the application of a moral code to the practice of medicine. Ideals and the Hippocratic Oath have been covered in another article but it... Try our Symptom Checker ...

What is Medical Baseline? The California Public Utiltiies Commission’s (CPUC) Medical Baseline Program is an assistance program for residential customers who have special energy needs due to qualifying medical conditions. It is based solely on medical conditions and there is no income requirement. The program provides:

The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12.The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), ... SCE at 1-800-655-4555 to discuss additional amounts. SCE 14-746 REV 8/22. Medical Baseline Allowance Application Patient's Last Name: First Name: Device: Electricity Gas Device: Electricity Gas Device: Electricity GasMedical Baseline program customers who are enrolled in an income-qualified program, such as the California Alternate Rates for Energy (CARE) or Family Electric Rate Assistance (FERA) programs, and live in a high fire risk area are also now eligible for the Critical Care Backup Battery Program, which provides a free, portable backup battery ...Once they sign off on the application, the baseline allowance will be added to your account. You can also print out a PDF copy of the application and complete it by hand. It will to be signed by a medical practitioner to certify the medical condition. Mail the completed and signed application form to: PG&E Attention: Medical Baseline P.O. Box …You can complete the Medical Baseline application online by visiting our Apply for the Medical Baseline Program page. After completing the application, you will be emailed a …Applying for SSI requires 2 steps. You will need to complete the online Child Disability Report AND, with the help of a Social Security representative, complete an Application …Application software are computer programs that allow users to perform specific tasks. These programs are commonly referred to as “apps,” and are usually completely self-contained ...Qualifying Medical-Based Need ; Help Someone Avoid Disruption of Service ; Assistance for Those with Limited Vision; Referrals to Social Services Agencies ; One-time Assistance Bill Assistance ; Low Income Federal Financial Aid for Qualifying Customers ; Savings Center. Overview; Tips. Home Electrification; Take a Home Energy Survey ...Qualifications for the Medical Baseline Allotment include: Dependent on life-support equipment used in the home. A paraplegic, hemiplegic, quadriplegic, or multiple sclerosis patient with additional heating and/or air-conditioning needs. A scleroderma patient with additional heating needs. Being treated for a life-threatening illness ...Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1.

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The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427 …Customers who reside in high fire risk areas and are currently enrolled in our Medical Baseline Allowance program, and who require the regular use of electrically powered medical equipment or another qualifying medical device, are eligible for the Critical Care Backup Battery program.. If we have contacted you about this program, you may be …Anyone who believes they may be eligible for additional assistance due to a qualifying medical condition should consider applying for a PGE medical baseline ...The standard Medical Baseline allowance is 16.5 kilowatt-hours of electricity and/or 0.822 therms of natural gas per day, which is in addition to your daily standard Baseline allocation. If this allowance does not meet your medical needs, please contact SDG&E at 1-800-411-7343 to discuss additional amounts. SDG&E offers TDD/TTY at 1-877-889-7343.The Standard Medical Baseline Allowance is 16.438 kWh of electricity and/or 0.82192 therms of natural gas per day, which is in addition to your daily standard Baseline Allocation. If this allowance does not meet your medical needs, please contact PG&E at 1 800 743 5000 to discuss additional amounts. The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/19. Superscript text contains small letters that appear above the type's baseline. Exponents ('²') appear in superscript text, as do ordinal indicators ('1ˢᵗ') and trademark symbols ('...The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/19.Oct 10, 2022 ... ... application and NEM agreement in the near future. What ... medical baseline + solar. I don't really understand how the medical baseline allowance ...Overview. Benefits. Eligibility Requirements. Financial Criteria. Medical Criteria. Qualifying When Over the Limits. How to Apply. Before You Apply. Application … ….

The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12.The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts.By Your Bill. Add a monthly fixed donation amount to your bill (ie. $5) or make a one-time donation in any amount. Call 1-800-205-8596. Expose as Block. No. Add Horizontal line. Off. Southern California Edison partners with the United Way to help qualified customers pay their electric bills – apply or donate today.your paper application to: PG&E Billing Center Medical Baseline, P.O. Box 8329, Stockton, CA 95208. STEP 4 Signature I certify the above information is correct. I also certify the Medical Baseline resident lives full-time at this address and requires or continues to require the Medical Baseline program.Start, Stop, and Move. Gas Appliance Check. Power Quality. Letters of Credit or Residency. Request Change of Mailing Address. Request Name Change on Account. Continuity of Service Agreement. Letter of Authorization. Service Upgrade for Your Home or Business.Once they sign off on the application, the baseline allowance will be added to your account. You can also print out a PDF copy of the application and complete it by hand. It will to be signed by a medical practitioner to certify the medical condition. Mail the completed and signed application form to: PG&E Attention: Medical Baseline P.O. Box …Medical Baseline program customers who are enrolled in an income-qualified program, such as the California Alternate Rates for Energy (CARE) or Family Electric Rate Assistance (FERA) programs, and ...If you or someone in your household has a qualifying medical condition or a need for certain medical devices, you may qualify for the Medical Baseline Allowance Program. Apply today to see if you can receive more …How do I apply for MBL? You can apply to the Medical Baseline Allowance Program online, by mail, or with our assistance by phone. a. Online Application: The fastest and most convenient method is to apply online. Visit sce.com/mbl and navigate to the “Apply” tab. You will need to fully complete the online application with all requested ... Medical baseline allowance application, The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. , The Medical Baseline Program, also known as Medical Baseline Allowance, is an assistance program for residential customers who depend on power for certain medical …, Ethics involves the application of a moral code to the practice of medicine. Ideals and the Hippocratic Oath have been covered in another article but it... Try our Symptom Checker ..., We accept applications via email from your medical provider. Mail the completed application to: SoCalGas Medical Baseline Allowance Program. M. L. GT19A1. P.O. Box 513249 Los Angeles, CA 90051-1249. Fax: 213-244-4665. Email: [email protected]. 2021 Southern California Gas Company., Are you a pre-medical student looking to gain hands-on experience in the medical field? A pre-medical summer internship may be just what you need to kickstart your career and set y..., Once they sign off on the application, the baseline allowance will be added to your account. You can also print out a PDF copy of the application and complete it by hand. It will to be signed by a medical practitioner to certify the medical condition. Mail the completed and signed application form to: PG&E Attention: Medical Baseline P.O. Box 8329 , The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. , MAIL APPLICATION TO: Southern California Edison Company Medical Baseline Department P.O. Box 9527 Azusa, CA 91702-9954 Date: mm/dd/yy PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (MD), DOCTOR OF OSTEOPATHY (DO), PHYSICIAN ASSISTANT (PA) OR NURSE PRACTITIONER (NP) I certify that the …, The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. , Qualifications for the Medical Baseline Allotment include: Dependent on life-support equipment used in the home. A paraplegic, hemiplegic, quadriplegic, or multiple sclerosis patient with additional heating and/or air-conditioning needs. A scleroderma patient with additional heating needs. Being treated for a life-threatening illness ..., Medical Baseline Allowance Program M. L. GT12F1 P.O. Box 513249 Los Angeles, CA 90051-1249 Once we receive your application, we will review the information. If you qualify, you will see the additional Medical Baseline Allowance on your bill. Please allow one full billing cycle for the change. If you move, you must notify Southern California Gas, Complete Medical Baseline Allowance BApplicationb - Southern California Edison online with US Legal Forms. Easily fill out PDF blank, ... California (U 338E) Cancelling Revised Revised Cal. PUC Sheet No. Cal. PUC Sheet No. 51882E 48140E Sheet 1 MEDICAL BASELINE ALLOWANCE APPLICATION Form 14746 (To. How It Works. Open form …, What is the Medical Baseline Allowance Program? The Medical Baseline Allowance Program provides an additional amount of gas and electricity at the lowest rates for residential customers. It is not a discount or rebate. In addition to your standard baseline allocation, the allowance received with the program is 16.5 kWh of electricity per day or, How do I recertify for the Medical Baseline Program? If you are an active Medical Baseline customer with a non-permanent medical condition and need to recertify for continued eligibility, please visit the Apply for the Medical Baseline Program page and follow the steps to complete the application process. SUBMIT FEEDBACK. If you are an …, Complete Medical Baseline Allowance BApplicationb - Southern California Edison online with US Legal Forms. Easily fill out PDF blank, ... California (U 338E) Cancelling Revised Revised Cal. PUC Sheet No. Cal. PUC Sheet No. 51882E 48140E Sheet 1 MEDICAL BASELINE ALLOWANCE APPLICATION Form 14746 (To. How It Works. Open form …, 1-800-DIAL-DWP (1-800-342-5397) Hearing/Speech Impaired (TDD) (1-800-432-7397) Send us an email. A discount on electric bills are available to customers who provide verification by a state-licensed physician that a full-time member of the household has a qualified medical condition., MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Allowance Program Enrollment and Recertification) I understand that: 1. If a licensed Medical Practitioner* certifies the resident’s medical condition is permanent, SDG&E will require completion of a form self-certifying resident’s continued eligibility for the Medical ..., Medical Baseline Allowance Application (Used for Medical Baseline Allowance Program Enrollment and Recertification) Part 2: To be completed by a licensed Medical Practitioner* (all of sections 1-5 must be filled out) I certify the medical condition and needs of my patient (please print): Patient’s Last Name: First Name: Customer Address: 1., Once you’ve completed an application and obtained verification from your licensed physician, surgeon or osteopath, an additional monthly medical allowance of 25 therms will be provided at the lowest (baseline) rate for hemiplegic / paraplegic / quadriplegic persons, multiple sclerosis / scleroderma patients and persons who are being treated for a life …, MEDICAL BASELINE ALLOWANCE APPLICATION (Used for Medical Baseline Enrollment and Re-Certification) PART 2: TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) I certify that the medical condition and needs of my patient (please print): Last name _____First name _____, Medical Conditions. Helping to keep you safe in the event of an outage. If you or someone in your household uses electrically-powered medical equipment, download and print our request form to be added to our medical conditions list. The form requires a physician's statement and signature. You must complete a form each year while using Dominion ..., To apply for the Medical Baseline Allowance program, fill out the customer section (Part 1) of the attached application. Next, have the patient’s qualifying medical professional complete and sign the remaining section (Part 2). Review the application to make sure it is complete and return it to: Southern California Edison Medical Baseline ..., Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable. MEDICAL BASELINE ALLOWANCE. On average this form takes 16 minutes to complete. The MEDICAL BASELINE ALLOWANCE form is 16 pages long …, 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 no longer requires the Medical Baseline Allowance. The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of ... , 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., Tokyo Medical University had been rigging the test scores to reduce the number of women being accepted for over a decade. In August, news that Tokyo Medical University had for year..., How APIs Work - How do APIs work? Learn more about how APIs work and their different applications at HowStuffWorks. Advertisement A conferencing API -- or any API for that matter -..., These programs are funded by California utility customers and administered by SoCalGas under the auspices of the California Public Utilities Commission. Program funds will be allocated on a first-come, first-served basis until such funds are no longer available. A program may be modified or terminated without prior notice., The latest Nimble Prospector update allows small businesses to build contact lists from social media and websites. Here's the full list of new features. A new browser extension all..., You can obtain an application for this program by calling BVES at 1-800-808-BVES(2837). A certification from a doctor, physician assistant, or nurse ..., Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME , The Standard Medical Baseline Allowance is 16.5 kilowatt-hours of electricity per day (0.822 therms of natural gas per day), which is in addition to your standard Baseline Allocation. If this allowance does not meet your medical needs, please contact SCE at 1-800-447-6620 to discuss additional amounts. SCE 14-746 REV 1/12., Medical Baseline Program Application—Part B (To be completed by Medical Practitioner *.) Medical Practitioner’s Certification for Medical Baseline Program Enrollment and Recertification . STEP 5 To be completed by a qualified medical practitioner I certify the medical condition and needs of my patient: (Please print.) PATIENT’S LAST NAME