Enrollment Form for Group B Medicines:
PATIENT SECTION
PATIENT INFORMATION (All fields are required):
Patient Name: Gender: Male Female
Patient Address:
City: State: Zip Code:
E-Mail:
Telephone: Date of Birth: (MM/DD/YY):
Total Number of People Within Household (including applicant):
Total Annual Income for Entire Household:
Please submit documentation to support the financial information you’ve listed. Attached is:
Most recent federal tax return W-2 form Other
Do you have prescription coverage? Yes (If Yes, please complete section 2) No
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PATIENT PRIVACY AND CONSENT (Read and signature required below):
The information you provide will be used by Pfizer, the Pfizer Patient Assistance Foundation and parties acting on their behalf to determine
eligibility, to manage and improve the Pfizer RxPathways program, products and services, to communicate with you about your experience
with the Pfizer RxPathways program, and/or to send you materials and other helpful information and updates relating to Pfizer programs.
By signing below, I affirm that my answers and my proof-of-income documents are complete, true and accurate to the best of my knowledge.
I understand that:
• Completing this enrollment form does not guarantee that I will qualify for Pfizer RxPathways.
• Pfizer may verify the accuracy of the information I have provided and may ask for more financial and insurance information.
• Any medicines supplied by the Pfizer RxPathways program shall not be sold, traded, bartered or transferred.
• Pfizer reserves the right to change or cancel the Pfizer RxPathways program, or terminate my enrollment, at any time.
• The support provided in this program is not contingent on any future purchase.
I certify and attest that if I receive medicine(s) provided by Pfizer through the Pfizer RxPathways program:
• I will promptly contact Pfizer RxPathways if my financial status or insurance coverage changes.
• I will not seek to have this medicine or any cost from it counted in my Medicare Part D out-of-pocket expenses for prescription drugs.
• I will not seek reimbursement or credit for the medicine(s) from my prescription insurance provider or payor, including
Medicare Part D plans for any costs of medications.
• I will notify my insurance provider of the receipt of any medicines through Pfizer RxPathways.
• I have a signed copy of a current and completed HIPAA Authorization Form on record with my Prescriber so that my Prescriber may
share health information about me with the Pfizer RxPathways program, Pfizer Inc., and the Pfizer Patient Assistance Foundation Inc.
Signature of Patient
(Parent or guardian, if under 18 years of age) X Date:
PRESCRIPTION COVERAGE AND INSURANCE INFORMATION (All fields are required):
Is the Pfizer Medicine you have been prescribed covered on your prescription plan? Yes No
Please check the one box that best describes your prescription coverage type:
Medicare Part-D Medicaid Private/Employer State Healthcare Exchange Other
Primary Insurance Co. Name: Phone #:
Policy Holder Name: Policy Holder DOB:
Policy Holder SSN: Policy #: Group #:
Prescription Card Name: Phone #:
RxBin #: PCN# Policy #: Group #:
Secondary Insurance Co. Name: Phone #:
Policy Holder Name: Policy Holder DOB:
Policy Holder SSN: Policy #: Group #:
Prescription Card Name: Phone #:
RxBin #: PCN# Policy #: Group #:
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SUTENT IN Touch, a free support program for patients starting treatment (For Sutent patients only):
By checking this box, I agree that the information I provide will be used by Pfizer and parties acting on its behalf to send me the materials
I requested and other helpful information and updates on SUTENT and/or my condition as well as related treatments, products, offers and
services, including information about the Sutent In Touch Call Center. Pfizer may also use my information to communicate with me and
my health care provider in relation to my treatment.
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PHA640707-01 © 2014 Pfizer Inc. Printed in USA/April 2014 FRMRXP101
Pfizer RxPathways P.O. BOX 66976, ST. LOUIS, MO 63166-6976 T: 877-744-5675 F: 800-708-3430 PfizerRxPath.com
Group B [3]
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