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.

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:

Patient Information:

  • 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)?

Assistance Information:

  • 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 Information:

  • Insurance type (i.e., private, Medicare, Medicaid)
  • Policy holder name
  • Policy number
  • Insurer name

We look forward to assisting you!