Home
Forms Library
Gas medical certificate form

Physicians and SurgeonsMBC - Medical Board of California 2025

gas medical certificate form Preview on Page 1

See details

4.6 out of 5

51 votes

The document outlines the requirements for medical certification to prevent the disconnection of natural gas service for residential customers in Illinois due to medical necessity. It specifies that a licensed physician or local board of health must certify the patient's medical condition, including necessary details such as patient information and statements regarding the impact of utility disconnection on their health. A completed form must be submitted via email.

Here's how it works

01. Edit your gas medical certificate form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send gas medical certificate form pdf via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Physicians and SurgeonsMBC - Medical Board of California with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
Begin by entering the Nicor Gas Account number at the top of the form. This is essential for identifying the account associated with the medical certification.
Fill in the patient's phone numbers, including primary and secondary contacts, ensuring that you have accurate information for communication.
Provide the patient's full name and date of birth. This information is crucial for verifying their identity and medical needs.
If applicable, enter the account holder’s name and phone number if it differs from the patient’s details.
Complete the street address, city, and confirm residency by checking 'Yes' or 'No' regarding whether disconnection will aggravate a medical condition.
Select your role as a certifying medical professional (Registered Physician, Local Board of Health, Physician’s Assistant, Nurse Practitioner) and provide your signature along with your license number.
Once all fields are completed accurately, save your document and email it to G2NICORGASMEDCER@southernco.com for processing.

Start using our platform today to streamline your form completion process for free!

See more Physicians and SurgeonsMBC - Medical Board of California versions

We've got more versions of the Physicians and SurgeonsMBC - Medical Board of California form. Select the right Physicians and SurgeonsMBC - Medical Board of California version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2018	4.6 Satisfied (51 Votes)
2011	4 Satisfied (38 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I contact the California Medical Board?

Contact Us Central Complaint Unit. Complaints. Phone: (800) 633-2322. Consumer Information Unit. Licensing and Applications. Phone: (800) 633-2322. Enforcement Central File Room. Enforcement Document Requests. Executive Office. General Board Inquiries. Public Affairs. Media Inquiries and Public Record Requests.

How do I verify a doctors credentials in California?

Online License Search Welcome to the Medical Board of California Licensee Profile search page. Here you will find profiles for all physicians and other allied health care providers who are licensed/registered in the state of California. The profile provides information about the licensee.

How do I find out if a doctor has complaints in California?

When you search for a physician through the BreEZe Online License Lookup , the physicians profile will show medical malpractice judgments and arbitration awards of any amount reported to the Board since 1993.

How to check if someone is actually a doctor?

To research a doctor, youll need to start with his or her name and location. Go to the Federation of State Medical Boards (FSMB) website to check the basics with their DocInfo.org search function.

How do I check the reputation of a doctor?

Suppose you need to verify that your provider has an authentic DEA registration number. In that case, you can visit the DEAs website and search for provider identification, such as their name or registration number. You can also contact the DEA directly at 1-800-882-9539 to speak to a customer service representative.

nicor gas medical certificate

California Medical Board Complaint Lookup Medical Board of California license Lookup Physicians and surgeons bc medical board of california exam California Medical Board disciplinary actions Medical Board of California license renewal Medical Board of California login Medical Board of California phone number California medical license for foreign medical Graduates

What is unprofessional conduct in the Medical Board of California?

Unprofessional conduct (breach of confidence, record alteration, filing fraudulent insurance claims, misleading advertising, arrest or conviction) Office practice issues (failure to provide medical records to a patient, failure to sign a death certificate, patient abandonment.)