The customer of record will need to fill out and sign Part A of the Medical Baseline application. A qualified medical practitioner will need to fill out and sign Part B of the Medical Baseline application.
A qualified medical practitioner is a licensed physician, person licensed pursuant to the Osteopathic Initiative Act, nurse practitioner or physician assistant who can certify a patient eligibility as having a life-threatening condition or illness.
To find the “Medical Baseline Allowance” application and for more information, visit our Apply for the Medical Baseline Program page.