Get Baycare Pfsfa4001 2017

Filling out the BayCare PFSFA4001 form is an essential process for individuals seeking financial assistance for medical expenses incurred at BayCare Health System. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your financial assistance application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the ECD number, date of service, and CPI number in the designated fields at the top of the form.
3. Fill out the patient’s name, date of birth, and social security number in the appropriate sections. Make sure the information is accurate.
4. Provide both the physical and mailing addresses, along with an email address for correspondence. Be sure to include the city, state, and ZIP code for both addresses.
5. Indicate whether the patient is pregnant and if they are disabled by selecting 'Yes' or 'No' for each question.
6. Select the marital status from the options provided: married, single, divorced, or widowed.
7. Indicate if the patient is a U.S. citizen or a legal resident by selecting 'Yes' or 'No.'
8. List all household members, including the patient. For each member, provide their date of birth, social security number, citizenship status, relationship to the patient, and tax filing status.
9. Document the household income for each member. Include details about all income sources for the past 12 months. If applicable, explain any lack of income and the support received.
10. Complete the section regarding any health or auto insurance that could cover medical costs, providing the insurance policy number where applicable.
11. Review the completed form for accuracy. Sign and date the application, ensuring that a witness is present to sign as well.
12. Save your changes, and then you may choose to download, print, or share the form as needed.

Take the next step towards financial assistance by completing your application online.