Get Baycare Pfsfa4001 2022-2025

This guide provides step-by-step instructions on how to complete the BayCare PFSFA4001 financial assistance application online. By following these directions, users can ensure a smooth application process for financial support related to medical expenses incurred at BayCare Health System.

Follow the steps to complete your BayCare PFSFA4001 application online:

1. Press the ‘Get Form’ button to obtain the BayCare PFSFA4001 application and open it for editing.
2. Begin by filling in your ECD# (if known), the date of service, and your CPI# in the designated spaces.
3. Input your full name, date of birth, address, mailing address, email, and phone number as requested on the form.
4. Answer whether you are a US citizen or legal resident by selecting the appropriate option.
5. Provide information pertaining to the financial assistance screening questions to determine potential eligibility for services.
6. List names, dates of birth, gender, marital status, and relationship to the guarantor for all household members.
7. Document the total income sources for each household member for the past 12 months, including employer names and yearly gross income.
8. Detail all household assets including bank account information, type of vehicle, and any additional assets, along with their approximate values.
9. Answer any additional questions regarding food stamp benefits or if your current illness/injury is related to any accident.
10. Ensure that both the patient and witness sections are signed and dated on the same day before submission.
11. After completing the form, review all entered information for accuracy, save any changes, and download or print the form as required.

Complete your BayCare PFSFA4001 application online today for financial assistance with your medical expenses.