How to Apply/Apply Online
If you believe you would qualify for assistance through the HealthWell Foundation, you have two options to begin the application process.
- Online Application process
- Call our hotline at 800-675-8416. Agents are available Monday–Friday 9 a.m. – 5 p.m. EST.
Whether you use the online process or call the hotline, please make sure you have the needed information on hand. Anyway you apply, you will need to supply the following:
- First and last name
- Social security number*
- Date of birth
- Email address (optional)
- Phone number
- Referral source (note: a drop down menu will be provided)
- Street address, city, state, zip code
Patient Financial Information:
- How many people are in the patient’s household?
- What is the annual household income (not just patient’s income)?
- Fund to which the patient is applying for assistance
- Type of assistance patient is requesting (copay or premium, note: not all funds offer premium assistance)
Provider Contact Information:
- Contact first and last name
- Contact relationship (note: a drop down menu will be provided)
- Contact email address (required for online application)
- Contact phone number
- Contact fax number (a copy of the pre-approval letter and the Statement of Treatment will be faxed to this number)
- Insurance type (i.e., private, Medicare, Medicaid)
- Policy holder name
- Policy number
- Insurer name
We look forward to assisting you!
*If you do not have a Social Security Number, you will need to call 1-800-675-8416 to speak to a HealthWell representative.