Application and return it to the Financial Assistance Department 2025

1. Click ‘Get Form’ to open the application in our editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. Sign and date the application at the bottom. A witness signature is required but notarization is not necessary.
7. 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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