Apply for Patient

Providers and patient advocates can apply on behalf of a patient two ways:

• Online. To get started, click here
• By phone, call (800) 675-8416

It is free to apply.  Before you begin the application process, please have the following information handy:

• Patient contact information (name, address, telephone number, social security number, date of birth)
• Patient insurance information and ID (i.e., insurance card(s))
• Patient income information (total household income, total household size)
• Prescribing physician information (name, address, telephone number, contact name)
• Whether the patient is applying for copayment or premium assistance (can only receive one or the other)

Step 1
Complete the online application or provide the information to an agent when you call.

Step 2
Fax us all parts of the application, including the Patient Application with the patient’s signature (or just the patient attestation if you applied online), the Statement of Treatment with the prescribing provider’s signature, and a copy of the patient’s most recent tax forms as proof of income. Please note that we cannot begin to review an application until we have all of these items. For fastest service, please fax these items to us at (800) 282-7692, but if you do not have access to a fax machine, you may mail us these materials to: HealthWell Foundation, P.O. Box 4133, Gaithersburg, MD 20878.

Once we receive all parts of the application, we will review the assistance request. A complete application includes:

• Patient Attestation (online requests only)
• Patient Application with the patient’s signature (if did not apply online)
• Statement of Treatment with provider’s signature
• Income documentation (for a list of acceptable income documentation click here)

The review process takes 3-5 business days once we receive all parts of the application. To check on the status of an application, call (800) 675-8416 and follow the instructions.

To see the eligibility criteria, please click here
If you are ready to begin the application process, please click here.
Have a question? Please visit our FAQ page.

Next Steps

After a Patient is Enrolled
When enrolled, the Foundation allocates each patient a grant for full or partial assistance for up to 12 months. Patients or their providers then submit invoices or receipts to receive reimbursement. The foundation typically sends awards directly to the insurer, pharmacy, physician, or other provider. However, in some cases it may send awards directly to patients to reimburse them for expenses they must pay themselves.

In some cases, patients may receive a HealthWell pharmacy card that they can take to their pharmacy when they fill their prescription. Most pharmacies can accept the card to pay the patient’s copayment at the time of dispensing. In these cases, no reimbursement is necessary. The HealthWell pharmacy card also works with most mail order or specialty pharmacies.

The HealthWell Foundation does not restrict the medications that patients use as long as the medication is approved by the Food and Drug Administration and is being used to treat a condition that falls within a funded area. However, we do focus on helping patients with extreme treatment costs and therefore typically do not reimburse for very low cost treatments, such as generics and steroids. When these lower cost treatments represent a financial hardship to a particular patient, they may be reimbursed on an exception basis.

The Foundation also does not restrict the provider or pharmacy that the patient selects, and patients are free to change providers or pharmacies at any time without affecting a patient’s eligibility for assistance.

The HealthWell Foundation reserves the right to change its program in its entirety or with respect to any applicant at any time with or without notice.

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