Applications

Patients and their advocates may apply to the HealthWell Foundation^® for assistance.

To begin the application process, please have the following information available:

• Patient demographic information (name, address, telephone number, social security number, date of birth)
• Patient insurance information (i.e., insurance card(s))
• Patient income information (total household income, total household size)
• Prescribing/treating physician information (name, address, telephone number, contact name if appropriate)

If you are ready to begin the application process, please click here.

Have a question? Please visit our FAQ page.

For more information or to receive an application by mail, please Contact Us