SCE Medical Baseline Form PDF Details

Are you or someone you know recently looking to gain medical clearance for a hospital procedure? Then the SCE Medical Baseline Form may be essential in allowing your healthcare provider to make an informed decision. This form acts as a bridge between providers and patients, helping facilitate the understanding of medical conditions, allergies, medications, surgeries, and other significant events that have shaped the patient’s health over time. In this blog post we will discuss what exactly is required in completing a baseline form so that you can confidently seek out medical treatment or clearance with ease.

QuestionAnswer
Form Name SCE Medical Baseline Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names medical baseline allowance application, sce com medical baseline form, medical baseline allowance, southern california edison medical baseline

Form Preview Example

Medical Baseline Allowance Application

(Used for Medical Baseline Enrollment and Re-Certification)

PART I: TO BE COMPLETED BY CUSTOMER (please print)

SCE Customer Account No.:

2-

Service Account No.:

3-

Customer’s Name (as it appears on your bill):

Name of Medical Baseline Patient at Residence (if different):

Service Address:

Customer’s Mailing Address (if different):

Home Phone:

()

Alternate Phone:

()

FOR CUSTOMERS BILLED BY SOMEONE OTHER THAN SCE:

Name of Mobile Home or Apartment Complex:

Complex Address:

Unit/Space:

Complex Manager’s Name:

Complex Phone:

()

Tenant’s Name:

Tenant’s Phone:

()

SCE MEDICAL BASELINE ALTERNATE CONTACT INFORMATION:

Upon completion of this application, we will automatically notify you of planned, unplanned, and rotating outages by phone. We also have the capability of notifying you of outages by e-mail, text messaging, or teletypewriter (TTY). If you already receive outage notifications from us and want to continue, or if you are not currently receiving outage notifications but would like to, please indicate your preferred method of receiving outage information below:

¡Phone (please indicate telephone number):

()

¡TTY (please indicate telephone number):

()

¡Text message (please indicate cell telephone number):

()

¡ E-mail (please indicate e-mail address):

¡ I do not wish for SCE to contact me with outage information.

CUSTOMER UNDERSTANDS THAT:

1If a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA) or Nurse Practitioner (NP) certifies the resident’s medical condition is permanent, the Medical Baseline resident must complete a form self-certifying his/her continued eligibility for Medical Baseline every two years.

2If a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA) or Nurse Practitioner (NP) certifies the resident’s medical condition is not permanent, the Medical Baseline resident must complete a form self-certifying his/her continued eligibility for Medical Baseline each year and the customer must submit a new application with a doctor’s certification every two years.

3If the resident is visually impaired, the customer may contact SCE to request special notification when either re-certification (to complete a new application with a doctor’s certification) or self-certification forms are mailed.

4SCE cannot guarantee uninterrupted gas and electric service and customers are responsible for making alternate arrangements in the event of a gas or 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 no longer requires the Medical Baseline Allowance.

Customer Signature:

Date: mm/dd/yy

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

Medical Baseline Allowance Application

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 medical condition and needs of my patient (please print):

Patient's Last Name:

First Name:

1. REQUIRES USE OF ELECTRICALLY-OPERATED MEDICAL DEVICES* (check one)

¡ Yes ¡ No

 

The following electrically-operated medical device(s) is (are) used in the above-named patient’s home:

 

 

 

 

 

 

 

Device:

 

¡ Electricity

¡ Gas

 

 

 

 

 

 

 

 

 

 

Device:

 

¡ Electricity

¡ Gas

 

 

 

 

 

 

 

 

 

 

Device:

 

¡ Electricity

¡ Gas

 

 

 

 

 

*A qualifying electrically-operated medical device is any medical device used to sustain life or relied upon for mobility. This device must run on gas or electricity supplied by SCE. 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 do not qualify.

2. IS THE PATIENT UNDER HOSPICE CARE: (check one) ¡ Yes ¡ No

3.REQUIRES HEATING AND COOLING:

Standard Medical Baseline Allowances are available for heating and/or cooling if the patient is Paraplegic, Quadriplegic, Hemiplegic, has Multiple Sclerosis or Scleroderma. Standard Medical Baseline Allowances are also available if the patient 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.

Requires Standard Medical Baseline Allowance for heating: Requires Standard Medical Baseline Allowance for cooling:

(check one)

¡ Yes

¡ No

(check one)

¡ Yes

¡ No

4. I CERTIFY THAT THE MEDICAL DEVICE(S) AND/OR ADDITIONAL HEATING OR COOLING WILL BE REQUIRED FOR

APPROXIMATELY: (check one)

¡ No. of Years ______________

or ¡ Permanently

5.IF THE EQUIPMENT IS FOR LIFE-SUPPORT PURPOSES, PLEASE INDICATE BELOW THE PATIENT’S TOLERANCE TIME ABSENT THE EQUIPMENT: (check one)

¡ 2 Hours or Less ¡ More Than 2 Hours

MD, DO, PA, NP Name (please print):

 

Phone:

(

)

 

 

 

 

 

Office Address:

MD, DO, PA, NP State License or Military License Number:

Signature of Doctor (MD, DO, PA, NP signature only):

Date: mm/dd/yy

SCE reserves the right to verify information contained on this application with the authorizing physician.

FOR SCE USE ONLY:

Date Received: _______________

Medical Baseline Allocation: _________ Electric Unit(s): _________ Gas Unit(s): _________

Recertification:

¡ Self-Certify Every 2 Years

¡ Self-Certify Annually: MD, DO, PA, NP Certification Every 2 Years

 

 

MAIL APPLICATION TO:

Southern California Edison Company

 

 

 

Medical Baseline Department

P.O. Box 9527

Azusa, CA 91702-9954

How to Edit SCE Medical Baseline Form Online for Free

medical baseline allowance can be completed online very easily. Simply use FormsPal PDF editing tool to accomplish the job fast. We are committed to providing you the perfect experience with our tool by consistently releasing new capabilities and enhancements. With these improvements, using our tool becomes easier than ever! Here is what you will have to do to begin:

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Filling out this PDF needs focus on details. Ensure that each blank field is filled in properly.

1. While filling out the medical baseline allowance, make certain to incorporate all of the necessary fields in the corresponding area. It will help facilitate the process, allowing your information to be processed quickly and properly.

Step # 1 for filling in sce forms

2. Right after performing the previous section, go on to the next part and complete all required particulars in all these fields - Upon completion of this, Phone please indicate telephone, TTY please indicate telephone, Text message please indicate cell, Email please indicate email, I do not wish for SCE to contact, CUSTOMER UNDERSTANDS THAT, If a Medical Doctor MD Doctor of, If a Medical Doctor MD Doctor of, If the resident is visually, SCE cannot guarantee, the event of a gas or electric, I certify that the above, Customer Signature, and Date mmddyy.

sce forms completion process outlined (portion 2)

3. Completing I certify that the medical, Patients Last Name, First Name, REQUIRES USE OF, Yes No, The following electricallyoperated, Device, Device, Device, Electricity, Gas, Electricity, Gas, Electricity, and Gas is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Device, Gas, and The following electricallyoperated of sce forms

4. This particular part comes next with these particular fields to look at: Requires Standard Medical Baseline, Requires Standard Medical Baseline, Yes No Yes No, I CERTIFY THAT THE MEDICAL, APPROXIMATELY check one, No of Years or Permanently, IF THE EQUIPMENT IS FOR, EQUIPMENT check one Hours or Less, More Than Hours, MD DO PA NP Name please print, Phone, Office Address, MD DO PA NP State License or, Signature of Doctor MD DO PA NP, and Date mmddyy.

Filling in part 4 of sce forms

5. This very last point to submit this document is crucial. Make sure to fill out the required form fields, for example Recertification SelfCertify Every, SelfCertify Annually MD DO PA NP, MAIL APPLICATION TO, Southern California Edison Company, Medical Baseline Department, PO Box, and Azusa CA, before finalizing. If not, it may generate an unfinished and possibly invalid form!

sce forms writing process detailed (part 5)

It's easy to make errors while filling in the Southern California Edison Company, hence make sure to take another look before you'll send it in.

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