01. Edit your bjcwallet online
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Patacct bjc org 2026
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02. Sign it in a few clicks
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- Click ‘Get Form’ to open the Financial Assistance Evaluation form in the editor.
- Begin by filling out the 'Patient Information' section. Enter your date of birth, name, and contact details. If applicable, provide the Social Security Number, noting that it is optional.
- In the 'Employment Information' section, list your employer's details as well as those of your spouse or partner if relevant.
- Answer the questions in the 'Other Information' section regarding accidents or crimes related to your medical services. Provide information about dependents and any marital status changes.
- Complete the 'Insurance Coverages' section by listing all relevant insurance types and details.
- Fill out the 'Monthly Income and Expenses' section accurately. Attach proof of income as specified in the instructions.
- Finally, review all entries for accuracy before signing and dating the certification at the end of the form.
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