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. Any way 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
  • Street address, city, state, zip code

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

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
  • Contact email address (required for online application)
  • Contact phone number
  • Contact fax number (a copy of the approval letter will be faxed to this number)

Insurance Information:

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

We look forward to assisting you!