Apply for Patient
Anyone with the patient’s permission may apply for a grant on the patient’s behalf. If you are a health care provider, staff from a provider’s office, a pharmacy representative, or social worker applying on behalf of your patient, you must use the Provider Portal or Pharmacy Portal to complete and submit your application. Click the Provider Portal or Pharmacy Portal link below to get started.
- Provider Portal
- Pharmacy Portal
- Apply by phone. Call (800) 675-8416. We strongly encourage providers, pharmacies, and social workers to use the Provider Portal or Pharmacy Portal to apply so that patients can readily access our hotline care managers.
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, prescription information and ID (i.e., insurance and policy information and prescription card(s))
- Patient income information (total household income, total household size)
- Prescribing physician information (name, address, telephone number, fax number, contact name)
- 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)
*If the patient does not have a Social Security Number, you will need to call (800) 675-8416 to speak to a HealthWell representative.
If the patient is approved, via phone or online, we will send an approval letter with the enrollment period dates and grant amount to the patient. The approval letter will provide the patient with a Reimbursement Request Form based on the type of assistance requested and instructions for submitting the reimbursement OR a pharmacy card (fund appropriate). In addition, we will fax a copy of the approval letter to you as long as your fax number was provided.