Baptist Charity Care Letter Request

Baptist Charity Care Letter Request
Your Baptist Charity Care letter is a very important document for your use when you visit the lab, radiology, or any specialists at Baptist Health. Please keep your letter in a safe place.

It can take up to 30 days from the day that you are approved to be a patient at MOM to receive your letter. If you have not received your letter after 30 days, please complete the form below. A MOM staff member or volunteer will check on the status of your letter and contact you via phone or text.
Today's Date*

MonthDayYear
Date
Patient Name*

PrefixFirst NameLast Name
Patient Birth Date*

MonthDayYear
Patient E-Mail

Confirmation EmailConfirm E-mail
Patient Cell Phone Number*

Area CodePhone Number
Can we text you at this number?*

YesNo
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: