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Request for Financial Assistance Form







Request for Financial Assistance

Please bring proof of the following items to:

Bay Regional Medical Center:
1900 Columbus Ave.
Bay City, MI 48708
Patient Financial Office

Hours:
8:00 A.M. to 4:00 P.M. Monday, Wednesday, and Thursday
8:00 A.M. to Noon Tuesday and Friday

To find the Patient Financial Office you go to the East Campus of Bay Regional Medical

Center. Go through the doors that face Columbus Ave. and the Patient Financial Office will be the first door on the left. No Appointment Necessary.

If you have any questions please call Sue Bourdon at (989) 894-3109 or Sherry Dengler at (989) 894-9598

  • Income for the last 2 months
    • Check Stubs or Print out from Employer
    • Social Security
    • Child Support
    • Interest
    • Pension
    • Workman or Unemployment Compensation
    • Any other Income
  • Your last 1040 (Federal Income Tax Form)
  • All Bank Statements:
    • Checking
    • Savings
    • IRA
    • Annuities
    • CD’s
  • Bills
    • House Payment or Rent
    • Car Payments
    • Utilities
    • Phone
    • Property Taxes
    • Insurance
      • Car
      • Home
      • Health
      • Life
    • Gas for Auto
    • Food/Groceries
    • Charge Accounts
    • Loans
    • Any other bills you may pay out
  • RFA


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© All rights reserved 2010 Bay Regional Medical Center 1900 Columbus Avenue Bay City, MI 48708 (989) 894-3000