How to Apply

Once you’ve determined that HealthWell offers assistance for your disease and that you are eligible for assistance, it’s time to apply. The application process is free.  Patients, providers, and advocates can apply to HealthWell two ways:

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

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 from the same fund)

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, 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. If you do not have access to a fax machine, you may mail these materials to: HealthWell Foundation, P.O. Box 4133, Gaithersburg, MD 20878. Please be sure to keep a copy of all documents for your files before sending them to HealthWell.

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

• Patient Application with the patient’s signature (if you 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.