ATTENTION: HealthWell Foundation’s hotline will close at 2:00 p.m. on Friday, October 11, 2024 for internal meetings and will remain closed on Monday, October 14, 2024 in observance of the federal holiday. The hotline will re-open on Tuesday, October 15, 2024, at 9:00 a.m. We encourage you to continue to use our Patient, Pharmacy and Provider Portals during this time. If you are contacting us about a payment or grant, please email us at [email protected] and a representative will respond to your message as quickly as possible when our hotline re-opens. We apologize for any inconvenience and look forward to serving you. The HealthWell Team
Forms
Reimbursement Forms
- Reimbursement Request Form – Copayment (Formulario de Solicitud de Reembolso – Copago)
- Reimbursement Request Form – Premium (Formulario de Solicitud de Reembolso – 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)
