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Financial Assistance Application


Financial Assistance Application

I understand that the information, which I submit concerning my annual income, family size and assets, is subject to verification by Lakeland Healthcare. I also understand that if the information which I submit is determined to be false, such a determination may result in a rejection of this application, and that the balance owing is due and payable immediately.

Once you have completed the form please submit it below along with the other requested documents and a Representative from the Lakeland Health Patient Accounts Department will reach out to you once your application with supporting documentation is reviewed.

Forms and documentation can also be submitted by mailing to:

Lakeland Patient Accounts
PO Box 410
St Joseph, MI 49085

You may contact us by phone at 269.428.5007 or toll free 866.414.7572,
Monday through Friday 8:00 am to 5:00 pm.

Upload Financial Assistance Application
Upload three months pay stubs/unemployment
Last three months Bank Statements
Latest tax return
Proof of citizenship/residency
Medical Denial (if applied)
No Income (If no income, a letter from the person supporting you including relationship.)
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