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Application and return it to the Financial Assistance Department 2026
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How to use or fill out the Financial Assistance Application and return it to the Financial Assistance Department
Ease of Setup
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Ease of Use
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- Click ‘Get Form’ to open the application in our editor.
- Begin by entering your ECD number, Date of Service, and CPI number at the top of the form. This information is essential for processing your application.
- Fill in your personal details including Patient Name, Date of Birth, Social Security Number, and contact information. Ensure accuracy as this will be used for communication regarding your application.
- Complete the Household Information section by listing all household members, their relationship to you, and their respective income sources. Remember to include financial information for a full 12 months.
- In the Household Income section, detail all income sources for each member listed. If there are no income sources, provide a letter of support from someone assisting you.
- Sign and date the application at the bottom. A witness signature is required but notarization is not necessary.
- Once completed, save your document and return it via email to finassist@baycare.org or fax it to (813) 635-7731.
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