Physicians and SurgeonsMBC - Medical Board of California 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Fill in the patient's phone numbers, including primary and secondary contacts, ensuring that you have accurate information for communication.
4. Provide the patient's full name and date of birth. This information is crucial for verifying their identity and medical needs.
5. If applicable, enter the account holder’s name and phone number if it differs from the patient’s details.
6. Complete the street address, city, and confirm residency by checking 'Yes' or 'No' regarding whether disconnection will aggravate a medical condition.
7. 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.
8. Once all fields are completed accurately, save your document and email it to G2NICORGASMEDCER@southernco.com for processing.

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