ATTENTION: HealthWell Foundation headquarters and hotline will be closed on Monday, February 17, 2025, in observance of the holiday and will re-open on Tuesday, February 18, 2025, at 9:00 a.m. We encourage you to continue to use our Patient, Pharmacy and Provider Portals during this time. If you have a question that cannot be answered by visiting the portal, please send an email to [email protected]. We appreciate your patience and look forward to serving you. The HealthWell Team
Forms
Instructions for Reimbursement
Reimbursement Forms
- Reimbursement Request Form – Copayment (Formulario de Solicitud de Reembolso – Copago)
- Reimbursement Request Form – Premium
- Travel Fund Reimbursement Form
Enrollment Forms
- Cancer-Related Behavioral Health Fund Form
- Emergency/Medical Workers Behavioral Health Fund Form
- Oncology Caregiver Behavioral Health Fund Form
- Oncology Caregiver Behavioral Health Fund Residency Verification Form
- Diagnosis Verification Form (Verificación de Diagnóstico)
- Household Size and Income Worksheet (Planilla de Cálculo del Tamaño e Ingresos del Hogar)