Apply for Patient

Physicians, Social Workers, Nurses, Office Personnel, and Advocates - We Are Here For You! The HealthWell Foundation stands ready to work with you to assist your patients! As a provider, we know you are busy with your patients throughout the day, which is why we want to make your HealthWell experience as easy and efficient as possible.

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

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 and prescription information and ID (i.e., insurance and pharmacy card(s))
  • Patient income information (total household income, total household size)
  • Prescribing physician information (name, address, telephone number, fax 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
If the patient is pre-approved, submit the following required documentation within 30 days:

  • Complete Statement of Treatment with the prescribing provider’s signature
  • A copy of the patient’s insurance and pharmacy card(s) – front and back.
  • If requesting premium assistance, also include:
    • Documentation from the patient’s insurer or employer confirming the portion of the health insurance premium the patient is responsible for paying 
    • Documentation that the patient’s insurance will cover the medications for the disease state.  We accept any of the following:
      • Letter from insurer, or
      • Explanation of Benefits (EOB) form (must include patient name, insurer name, drug name and copay amount), or
      • Recent pharmacy receipt (must include patient name, insurer name, drug name and copay amount)
  • For audit related purposes, you may be required to submit income documentation each year.

We must receive ALL the required documentation within 30 days of approval or the patient's grant will be closed. The patient can re-apply, however the grant start date will reset. Dates of service and costs incurred prior to the most recent start date will not be eligible for reimbursement. 

We will not call or send letters requesting any missing required documentation. It is the responsibility of the patient and provider to ensure we received the required documentation within 30 days of the pre-approval.

For the fastest service, please fax these items to us at (800) 282-7692. You will receive an automatic fax back confirmation which includes the number of pages received. In order for our fax confirmation to get to you, your fax machine number must be programmed into your machine.

To check on the status of a grant, you can register and use our secure online provider portal. To get started, please  click on the MY PATIENTS-MY PORTAL button below:


You can see our eligibility page here.
If you are ready to begin, our application page is here.
Have questions? Please visit our FAQ page.

*If you do not have a Social Security Number, you will need to call 1-800-675-8416 to speak to a HealthWell representative.