Bay Area Hospital is committed to ensuring our patients get the hospital care they need regardless of ability to pay for 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information, including your name, phone number, address, and date of birth. Ensure all details are accurate.
3. List all household members and their relationships to you. This section is crucial for determining eligibility based on family size.
4. Provide detailed income information for each household member. Include sources of income such as employment, disability, or social security. Make sure to enter monthly gross amounts.
5. Indicate any additional assets you may have by checking the relevant boxes and attaching recent statements for each asset listed.
6. Review the application thoroughly. Use 'N/A' for any sections that do not apply to you. Incomplete applications will be returned.
7. Sign and date the application along with your spouse if applicable. Submit the completed form along with required documentation either by mail or in person.

Start using our platform today to easily complete your financial assistance application!