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Healthwell foundation forms 2025

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The document is a reimbursement request form from the HealthWell Foundation for health insurance premium assistance. It collects patient and payee information, details about the insurance premium, and requires supporting documentation for reimbursement. The form emphasizes the need for accurate information and outlines the conditions under which reimbursement can be claimed.

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How does HealthWell verify income?

HealthWell has a proven track record of using donations effectively and efficiently. HealthWell received Charity Navigators Four Star Charity rating indicating that it exceeds industry standards and outperforms most peer organizations.

How do I apply for the HealthWell Foundation grant for individuals?

Attach a copy of your 1040 tax return from the previous year. If you filed an extension, please send a copy of the letter. If the attached documentation does not reflect your current financial situation, please provide a letter explaining how your income has changed and any extenuating circumstances.

How does medical verify income?

Once youre approved for a grant from one of our Disease Funds, you receive assistance for a rolling 12 months, after which you can reapply if needed and if funding is available. Upon approval, youll receive both a HealthWell Pharmacy Card and a Reimbursement Request Form for times when you need it.

What does HealthWell Foundation cover?

Have the patient apply online or by calling 800-675-8416. *If you do not have a Social Security Number, you will need to call 1-800-675-8416 to speak to a HealthWell representative. first-come, first-served basis.

Does health insurance check your income?

The Health Insurance Marketplace uses annual household income and other information to decide if you qualify for savings on health coverage through the Marketplace (like the premium tax credit) and other cost savings, like lower copayments, coinsurance, and deductibles (also called cost-sharing reductions).