Fill - Free fillable PFIZER PATIENT ASSISTANCE PROGRAM PDF form

PATIENT APPLICATION

PFIZER PATIENT ASSISTANCE PROGRAM

Phone 1-844-935-5269 | Fax 1-866-297-3471 | 2730 S. Edmonds Lane, Suite 300, Lewisville TX 75067

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 Patient Assistance Program, to communicate with you about your experience with the Pﬁzer Patient Assistance Program, and/or to send you materials

and other helpful information and updates relating to Pﬁzer programs.

Patient Declaration - By signing below, I certify that I cannot afford my medication, and

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 the Pﬁzer Patient Assistance Program. 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 Patient Assistance Program

shall not be sold, traded, bartered, or transferred. Pﬁzer reserves the right to change or

cancel the Pﬁzer Patient Assistance Program, or terminate my enrollment, at any time. The

support provided through this program is not contingent on any future purchase. If I am

enrolled in a Medicare Part D Plan and am eligible for the Pﬁzer Patient Assistance Program,

Pﬁzer will notify my Part D Plan of my enrollment in the Pﬁzer Patient Assistance Program.

I certify and attest that if I receive medicine(s) provided by Pﬁzer through the

Pﬁzer Patient Assistance Program: I will promptly contact the Pﬁzer Patient Assistance

Program 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 true out-of-pocket

costs (TrOOP) for prescription drugs. I will not submit claims, seek reimbursement or

credit for the medicine(s) from my prescription insurance provider or payor, including

Medicare Part D plans. I will notify my insurance provider of the receipt of any medicines

through the Pﬁzer Patient Assistance Program. 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 Patient Assistance

Program, Pﬁzer Inc., and the Pﬁzer Patient Assistance Foundation Inc.

*The Pﬁzer Patient Assistance Program is a joint program of Pﬁzer Inc. and the Pﬁzer Patient Assistance Foundation

™

. Free medicines from Pﬁzer are provided through the Pﬁzer Patient Assistance Foundation

™

. The

Pﬁzer Patient Assistance Foundation

™

is a separate legal entity from Pﬁzer Inc. with distinct legal restrictions.

Name:

Address:

City: State: ZIP:

Telephone (Day): Telephone (Evening):

E-mail (Please provide to speed up process):

Date of Birth (DOB):

PATIENT

INFORMATION

Address:

City: State: ZIP:

MEDICARE

PART D INSURANCE

MAILING ADDRESS

I conﬁrm that I do not have prescription drug coverage.

INSURANCE

INFORMATION

Total Number of People Within Household (including applicant): ____________

Total Annual Income for Entire Household: $ _________________

(The current annual household income includes current annual salary, Social Security, unemployment insurance beneﬁts, and workers’ compensation)

Please submit documentation to support the ﬁnancial information if you do not want your income to be veriﬁed electronically.

Attached is: Most recent federal tax return (1040 form) W-2 form Other

We must receive proof of income to determine eligibility for assistance.

If you are required to ﬁle a federal tax return, please provide a signed copy. Proof of income may include documents such as: copy of most

recent federal tax return, W-2 form(s), 1099 form, Social Security Award Letter or Check, or copies of three most recent pay stubs.

PATIENT

FINANCIAL

INFORMATION

Check here if reapplying for the Pﬁzer Patient Assistance Program.

Please complete the form where applicable and return via mail or fax. Pages 1 and 2 must be returned to XELSOURCE.

Patient Signature (Parent or Guardian, if under 18 years of age) Date

Patient Authorization for Electronic Income Veriﬁcation (Optional, but may reduce application review time)

I, the applicant named above, understand that I am providing “written instructions” to

Pﬁzer Inc. under the Fair Credit Reporting Act authorizing Pﬁzer Inc. to obtain information

from my credit proﬁle or other information from Experian

Income View

. I authorize

Pﬁzer Inc. to obtain such information solely for the purpose of determining ﬁnancial

qualiﬁcations for the Pﬁzer Patient Assistance Program. I also agree to provide additional

ﬁnancial documentation in a timely manner, if so requested. I understand that I must

afﬁrmatively agree to the terms in this notice by signing below in order to proceed in

the Pﬁzer Patient Assistance Program ﬁnancial screening process. I understand that I

am entitled to a copy of this Authorization upon request. This Authorization shall be valid

for two (2) years from the date of the signature of this form (unless a shorter period is

prescribed by law). I understand that I may cancel this Authorization at any time by mailing

a letter requesting such cancellation to 2730 S. Edmonds Lane, Suite 300, Lewisville,

TX 75067, but that this cancellation will not apply to any information already used or

disclosed through this Authorization.

Patient Authorization for Financial Screening: My signature certiﬁes that I have read

and understand the above statements, and agree to the outlined terms.

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HCP TO COMPLETE

Phone 1-844-935-5269 | Fax 1-866-297-3471 | 2730 S. Edmonds Lane, Suite 300, Lewisville TX 75067

PFIZER PATIENT ASSISTANCE PROGRAM

Name & Title: Specialty:

Payer Speciﬁc #: NPI #: Tax ID #:

State License #: DEA #:

Name of Facility:

Address:

City: State: ZIP:

Contact Name:

Contact Phone: Fax:

Contact E-mail Address:

PRESCRIBER

INFORMATION

(To be

completed by

the provider)

The information you provide will be used by Pﬁzer to improve and tailor our products and services to better serve you. The information will also

be used by the Pﬁzer Patient Assistance Foundation

and parties acting on their behalf to administer and improve the Pﬁzer Patient Assistance

Program, to communicate with you about your experience with the Pﬁzer Patient Assistance Program, and/or to send you materials and other

helpful information and updates relating to Pﬁzer programs.

By signing below, you, the Prescriber, understand and agree to the following: I will receive and secure my patient’s medication at my ofﬁce until it’s

dispensed to my patient, when applicable. Any medications supplied by Pﬁzer as a result of this enrollment form are for the use of the patient named on

this form only, and shall not be sold, traded, bartered, transferred, returned for credit, or submitted to any third party (such as Medicare, Medicaid, or other

beneﬁt provider) for reimbursement, nor will any cost related to it be applied toward the patient’s true out-of-pocket costs (TrOOP). I certify that the

information provided is current, complete, and accurate to the best of my knowledge. I certify that my decision to prescribe a Pﬁzer product is based

solely on my independent clinical judgment. I understand that completing this enrollment form does not guarantee that assistance will be provided to

my patient. I will comply with and abide by my State Practitioner Dispensing Laws for authorized Prescribers, when applicable. The medicine will be

provided only to this eligible and enrolled patient at no charge of any kind. Pﬁzer may contact the patient directly to conﬁrm the receipt of medications. The

information provided on this enrollment form is subject to random audits and veriﬁcation. Pﬁzer may change or cancel this program at any time; Pﬁzer

also reserves the right to terminate my patient’s enrollment at any time. I will notify the Pﬁzer Patient Assistance Program immediately if the Pﬁzer product

is no longer medically necessary for this patient’

s treatment or if my patient’s insurance or ﬁnancial status changes. I have a signed copy on ﬁle of my

patient’s current and completed HIPAA Authorization Form so that I may share patient health information with the Pﬁzer Patient Assistance Program,

Pﬁzer Inc., and the Pﬁzer Patient Assistance Foundation Inc.

Prescriber Signature X Date:

PRESCRIBER

CERTIFICATION

Note: If you are a New York prescriber, please attach state prescription form.

* The Pﬁzer Patient Assistance Program is a joint program of Pﬁzer Inc. and the Pﬁzer Patient Assistance Foundation

™

. Free medicines from Pﬁzer are provided through the Pﬁzer Patient

Assistance Foundation

™

. The Pﬁzer Patient Assistance Foundation

™

is a separate legal entity from Pﬁzer Inc. with distinct legal restrictions.

Prescriber Patient Other (please provide shipping address—NO PHARMACIES):

Address:

City: State: ZIP:

SHIP TO

CLINICAL AND

PRESCRIPTION

INFORMATION

Patient First Name: Patient Last Name:

Patient Date of Birth: Patient Phone:

Rx: XELJANZ 5 mg PO BID, 30-day supply XELJANZ 10 mg PO BID, 30-day supply

XELJANZ XR 11 mg PO QD, 30-day supply XELJANZ XR 22 mg PO QD, 30-day supply

Reﬁlls (up to 11):

Drug Allergies: Yes No If yes, please list medication(s) and associated reaction(s):

Patient’s current medication(s):

Prescribing Physician Signature—NO STAMPS (Dispense as written)

X Date:

Check here if the patient is reapplying for the Pﬁzer Patient Assistance Program.

Please complete the form where applicable and return via mail or fax. Pages 1 and 2 must be returned to XELSOURCE.

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Patient Authorization to Share Health Information

For details about how we collect and use personal

information, including applicable U.S. state privacy

rights and notices for California residents, please visit

www.pﬁzer.com/privacy.

By signing this form, I give my permission for my physicians,

pharmacies, laboratories, and other healthcare providers

(“Healthcare Providers”) and my health insurers to share my

health information with Pﬁzer Inc., the Pﬁzer Patient Assistance

Foundation, Pﬁzer afﬁliates and its vendors (collectively, “Pﬁzer”).

I understand that my health information includes information

relating to my medical condition, treatment, and insurance

coverage, as well as identifying information about me (including,

for example, my name, address, and date of birth). My health

information will be shared with Pﬁzer so that Pﬁzer may provide

me with various support and information to help me access a

Pﬁzer medicine, which may include the following, depending on

your program (collectively, “Patient Support Activities”):

•

Providing benefits investigations/verification and

reimbursement support, including:

–

Assisting with identiﬁcation of my insurer’s prior

authorization requirements

–

Assisting with identiﬁcation of my insurer’s requirements

for appealing a denied claim

•

Determining my eligibility for and helping me access

co-pay support or free drug programs

• Sending me a device and starter kit (where appropriate)

•

Communicating with my Healthcare Providers about a Pﬁzer

medicine and Patient Support Activities

•

Providing me with ﬁnancial assistance resources and

information if I’m eligible

•

Providing me with disease management and other educational

materials, as well as information about Pﬁzer’s products,

services, and programs, and may include sending me

surveys about my experience with Pﬁzer products, services,

and programs

Pﬁzer also may use my health information for quality assurance

purposes and to evaluate and improve our operations and services.

I understand that I do not have to sign this form, and choosing

not to sign will not affect my ability to receive treatment from

my Healthcare Providers or payment from my health insurer.

However, if I do not sign this form, XELSOURCE may not be able

to provide me with assistance.

I understand that once my health information is shared, it may

no longer be protected by federal privacy law. However, Pﬁzer

agrees to protect my health information and to use it for the

purposes described in this form or as required or permitted by

law. Select pharmacies may receive remuneration from Pﬁzer

in exchange for my health information and/or for any Patient

Support Activities provided to me.

I understand that this form will remain in effect for 4 years

from the date of my signature unless I provide written notice

that I would like to withdraw my approval to share my health

information sooner. If I would like to withdraw my approval,

I may contact my physician, or I may contact XELSOURCE

at 1-844-935-5269 or 2730 S. Edmonds Lane, Suite

300, Lewisville, TX 75067. This withdrawal will not affect the

use or sharing of my health information that took place before

I withdraw my approval. I understand I may receive a copy of

this form.

I also give my permission to receive communications from Pﬁzer,

XELSOURCE, and parties acting on their behalf, including text

message, email, a live operator, autodialer or prerecorded voice

at the phone number(s) provided to determine my eligibility

and provide beneﬁts veriﬁcation, prior authorization/appeals

assistance, and ﬁnancial assistance resources and information,

such as co-pay support or free drug programs, and for other

non-marketing purposes. If I have a caregiver, he or she has also

agreed to receive such communications from Pﬁzer, XELSOURCE,

and/or parties acting on their behalf for the purposes described

above, and I hereby give my permission for Pﬁzer, XELSOURCE,

and/or parties acting on their behalf to contact my caregiver

for such purposes. I understand that I (and, if applicable, my

caregiver) can opt-out of these communications at any time by

contacting XELSOURCE at 1-844-935-5269.

By checking this box and providing my cellular number, I consent to receive enrollment status, prescription

updates, and reﬁll reminders from XELSOURCE via text message. I will receive a welcome text asking me to reply

YES to opt-in. Message and data rates may apply; number of messages varies based on program use, but

is up to 10 texts per month. Reply STOP to cancel. Privacy policy available at www.pfizer.com/privacy and full

Terms and Conditions available at https://m.enrollsource.com/pfe

Please enter the number you would like to enroll

for texting ________________________.

XELSOURCE

Answers and Support

Signature of Patient Date

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