The HealthWell Foundation Diagnosis Verification Form is a one-page document your prescriber completes and signs to confirm your medical diagnosis when HealthWell cannot verify it electronically. To complete and submit it, download the form from HealthWell’s website, have your licensed provider fill in your diagnosis and the matching ICD-10 code, sign and date it, and return it through the provider portal or by fax. Until a completed form reaches HealthWell, your grant stays frozen and will not pay anything.
Why You Received the Request
HealthWell first tries to confirm your diagnosis automatically through pharmacy claims data or provider portals. When those checks come back inconclusive, the foundation asks for this form as the manual backup. You will only see the request if you already have a pending or active grant in a specific disease fund, and the diagnosis your provider lists must fall within the clinical parameters of that fund. A related but slightly different diagnosis code is the single most common reason forms get sent back.
Where to Download the Form
The form lives on HealthWell’s forms page at healthwellfoundation.org/about/what-we-do/forms, listed as the “General Diagnosis Form.” Your provider’s office can also pull it from the provider portal at healthwellfoundation.org/providerportal. Print it or save it as a PDF and bring it to your next appointment. You do not fill it out yourself.
What Your Provider Fills In
The form is short, but every field matters.1HealthWell Foundation. Diagnosis Verification Form Your prescriber needs to supply:
- Your full name as it appears on your HealthWell grant application.
- The specific diagnosis being treated and its ICD-10 code.
- The name and full address of the facility where you receive care, including city, state, and zip code.
- The prescriber’s printed name and credentials (MD, DO, PA, NP).
- The prescriber’s original signature and the date. An unsigned form is rejected outright.
By signing, the provider certifies they are licensed to prescribe in your state, that the diagnosis is accurate, and that they will supervise your treatment. The current form also allows a person authorized by the prescriber to complete and sign on the prescriber’s behalf, which helps when your doctor is hard to reach.
Who Can Sign
Any provider licensed and authorized to prescribe medication in your state can sign. That includes physicians (MD or DO), physician assistants, and nurse practitioners, along with any staff member the prescriber has formally authorized to sign for them.
Getting the ICD-10 Code Right
This is where most rejections happen. Each HealthWell disease fund covers a defined set of diagnoses, and the code your provider enters has to fall inside that set. A code for a clinically related but out-of-scope condition will come back as a rejection with a request for a corrected form. Before your provider writes anything down, tell them the exact name of the disease fund you were approved under. That context helps them pick the precise code HealthWell expects rather than a broader one pulled from your chart.
How to Submit It
Once the form is signed, you have two fast options:1HealthWell Foundation. Diagnosis Verification Form
- Upload the signed form through the provider portal at healthwellfoundation.org/providerportal. This creates an immediate receipt record and is the quickest route.
- Fax the completed form to (800) 282-7692.2HealthWell Foundation. About the Contact Center
If you have to mail a hard copy, send it to the Contact Center P.O. box, not the national headquarters:
HealthWell Foundation
P.O. Box 489
Buckeystown, MD 217173HealthWell Foundation. Contact Us
HealthWell warns that grant documents sent to the Germantown, MD headquarters instead of the P.O. box will see processing delays. The portal or fax are strongly preferred.
After You Submit
HealthWell staff review the form to confirm the diagnosis and ICD-10 code match the parameters of your disease fund. If everything lines up, your grant moves to active status and can begin paying eligible expenses. You can check progress through HealthWell’s online Application Status Lookup Tool or by calling the Contact Center at (800) 675-8416.2HealthWell Foundation. About the Contact Center
If the form is rejected, usually for a mismatched ICD-10 code or a missing signature, HealthWell will notify you and ask for a corrected version. A rejection does not cancel your grant. Your provider completes a new form with the correct information and resubmits it through the same channels.
Do Not Miss the 120-Day Deadline
Getting the form accepted is not the last step. HealthWell requires your first complete reimbursement request within 120 days of the date on your approval letter, or the grant may lapse. Most grants cover up to 12 months of therapy assistance, and the specific terms for yours are printed on the back of the approval letter.4HealthWell Foundation. Frequently Asked Questions Keep that letter where you can find it.