The HealthWell Foundation Income Verification Statement is a one-page form that documents your household income so the foundation can decide whether to cover your copays, premiums, deductibles, and other out-of-pocket medication costs. To complete it, you list each income source and amount on the form, sign and date it, and attach proof for every source you listed — usually your signed prior-year 1040, plus benefit letters or an explanatory letter if your situation has changed. You can download the form from HealthWell’s forms page, pick it up from a participating pharmacy or provider, or request one by calling (800) 675-8416.
The form itself is short. The attachments are where applications get delayed.
What the Form Asks For
The statement has two sections. The first is your individual income, broken into 16 categories. You only fill in the ones that apply to you.1HealthWell Foundation. Income Verification Statement
- Employment and self-employment: wages, rental property income, investment income, interest income, and dividends.
- Government benefits: Social Security Income, Social Security Disability, unemployment, Workers Compensation, Aid to Families with Dependent Children, and Temporary Aid to Needy Families.
- Retirement and other: pension, IRA distributions, alimony, charities/grants/gifts, and any other income with an explanation.
For each source, enter the dollar amount and pick the frequency: weekly, monthly, or yearly. For variable income like freelance work or seasonal employment, use an annualized figure rather than one month’s number.
The second section is a table listing each household member — their name, relationship to you, income source, amount, and frequency. Household income means the combined earnings of you and your legal spouse living in the same home.1HealthWell Foundation. Income Verification Statement
Documents You Need to Attach
HealthWell will not review the form on its own. You need to attach proof for every income source you listed. The primary document is your federal 1040 tax return from the previous year, and the second page must be signed. An unsigned return will delay the review. Your Adjusted Gross Income appears on line 11.2Internal Revenue Service. Adjusted Gross Income
If You Filed a Tax Extension
Attach a copy of your signed IRS Form 4868 along with your most recently filed 1040. The extension form by itself is not enough; HealthWell still needs actual income figures from a completed return.1HealthWell Foundation. Income Verification Statement
If You Did Not File a Return
You still need to document every source on your form. Benefit award letters or statements from the issuing agency work for Social Security, disability, and unemployment. The form doesn’t prescribe exact document types for every category; whatever you attach must clearly show the recipient’s name and the dollar amounts. If you’re unsure, call HealthWell at (800) 675-8416 before submitting.
If Your Income Has Changed
If your current situation no longer matches your most recent return — a job loss, a disability onset, a divorce — include a letter explaining the change and attach documents that confirm it, such as a termination notice or a benefit award letter. This is easy to overlook and it matters. A 1040 showing $90,000 would make you look ineligible on its own, even if you lost that job six months ago. The explanatory letter gives HealthWell the context to evaluate your actual current income.1HealthWell Foundation. Income Verification Statement
Filling Out and Signing
Go through the categories one at a time. Leave blank or enter zero for anything that doesn’t apply. The numbers you write on the form must match what your attachments show. A mismatch between the form and your 1040 or benefit letters is one of the fastest ways to get flagged for additional review.
Sign and date the form at the bottom. Your signature certifies that the information is true and complete.1HealthWell Foundation. Income Verification Statement Both the signature and date are required. A missing signature stops the review. Keep a copy of everything before you send it in.
How to Submit
Two options:
- Upload the completed form and all supporting documents through your patient, provider, or pharmacy portal on the HealthWell website.
- Fax everything to (800) 282-7692.
Submitting a blank or incomplete form delays the review.1HealthWell Foundation. Income Verification Statement
What Happens After You Submit
HealthWell’s initial grant approval is typically instant when you apply online or by phone — you find out right away whether you qualify based on what you provide.3HealthWell Foundation. Frequently Asked Questions The income document review is a separate step that happens after that. While it’s underway, your grant may be temporarily inactive until HealthWell confirms your income.4HealthWell Foundation. How to Get Reimbursed If anything is missing, the foundation will contact you and give you a window to respond.
Once approved, a grant is active for a 12-month cycle or until you use up the awarded amount, whichever comes first. Your approval letter spells out the terms, including reimbursement details.5HealthWell Foundation. HealthWell Foundation
Before You Start: Eligibility and Fund Status
Two things can make the whole packet moot, so confirm them first. You need health insurance of some kind (private, Medicare, Medicaid, or Tricare — uninsured patients don’t qualify), your diagnosis has to fall within one of HealthWell’s disease-specific funds with your medication listed as eligible, treatment has to be in the United States, and your household income must sit at or below the Federal Poverty Level threshold set for your fund, which is 300%, 400%, or 500% depending on the condition. HealthWell also factors in household size and local cost of living, so a nominally high income in an expensive metro isn’t an automatic disqualifier.6HealthWell Foundation. Eligibility Health Savings Accounts and Health Retirement Accounts aren’t treated as insurance and are evaluated case-by-case.
Second, check whether your fund is open. Funds close when money runs out, and HealthWell doesn’t keep a waitlist. Search for your condition on the disease funds page before you spend time gathering paperwork, and sign up for email or text alerts if the fund is closed so you’ll know when it reopens.7HealthWell Foundation. Disease Funds