Fill - Free fillable PFIZER PATIENT ASSISTANCE PROGRAM PDF form

Patient Declaration – 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 application 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 medications 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 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 the

Pﬁzer Patient Assistance Program:

•

I will promptly contact XELSOURCE if my ﬁnancial status or insurance

coverage changes.

• I will not seek to have the medicine(s) or any cost from it (them) counted

in my Medicare Part D out-of-pocket expenses for prescription drugs.

• I will not seek reimbursement or credit for any costs associated with

the medicine(s) from my prescription insurance provider or payer,

including Medicare Part D plans.

•

I will notify my insurance provider of the receipt of any medicine(s)

through the Pﬁzer Patient Assistance Program.

• I have a signed copy of a current and complete HIPAA Authorization

Form on record with my Prescriber so that my Prescriber may share

health information about me with Pﬁzer’s assistance programs,

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

The information you pro

vide will be used by Pﬁzer,

the Pﬁzer Patient Assistance Foundation, Inc., and parties acting on their behalf to

determine eligibility, to manage and improve Pﬁzer programs, products, and services, 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.

This information may be disclosed to entities to determine eligibility for other patient assistance programs as an alternate or supplement to

your co

verage for XELJANZ.

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

™

. The Pﬁzer Patient Assistance Foundation is a separate legal entity from Pﬁzer Inc with distinct legal restrictions.

Click here for XELJANZ full Prescribing Information, including BOXED WARNING and Medication Guide.

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

Patient Name:

Patient Address:

City: State: ZIP Code:

Telephone (Day): Telephone (Evening):

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

Date of Birth (DOB):

PATIENT

INFORMATION

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.

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.

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

PATIENT APPLICATION

PFIZER PATIENT ASSISTANCE PROGRAM

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Prescriber Name & Title: Prescriber Specialty:

Payer Speciﬁc #: NPI #: Tax ID #:

State License #: DEA #:

Name of Facility:

Prescriber Address:

City: State: ZIP Code:

Contact Name:

Contact Phone: Fax:

Contact E-mail Address:

PRESCRIBER

INFORMATION

(To be

completed by

the provider)

I certify that the information provided is current, complete, and accurate to the best of my knowledge. I will notify XELSOURCE immediately if

the Pﬁzer product is no longer medically necessary for this patient’s treatment. I certify that the Pﬁzer product is medically necessary for

this patient and I will be supervising the patient’s treatments. 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 Pﬁzer’s assistance programs, Pﬁzer Inc, and the Pﬁzer Patient Assistance

Foundation, Inc. I understand that any information provided is for the sole use of Pﬁzer and their agents and representatives to verify my patient’s

insurance coverage, to assess, if applicable, patient’s eligibility for participation in the Pﬁzer Patient Assistance Program and to otherwise

administer XELSOURCE and related services. I understand that application to the Pﬁzer Patient Assistance Program does not guarantee that

assistance will be obtained. I understand that Pﬁzer may change or cancel this program at any time. I understand that if my patient’s ﬁnancial

and/or insurance status changes, the patient may no longer be eligible for the Pﬁzer Patient Assistance Program, and I agree to immediately

notify a XELSOURCE representative if I become aware of changes in the patient’s insurance status. I agree that Pﬁzer may contact me for

additional information relating to this application either by fax or any other form of communication, including but not limited to e-mail and

telephone. I understand that I am under no obligation to prescribe any Pﬁzer product and that I have not received nor will I receive any beneﬁt

from Pﬁzer or their agents or representatives for prescribing a Pﬁzer product. I agree that I will not submit claims for product provided by the

Pﬁzer Patient Assistance Program.

The information you provide will be used by Pﬁzer, the Pﬁzer Patient Assistance Foundation, Inc., and parties acting on their behalf to

administer and improve Pﬁzer programs, products, and services, to communicate with you about your experience with Pﬁzer and the

Pﬁzer Patient Assistance Program, and/or to send you materials and other helpful information and updates relating to Pﬁzer programs.

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

™

. The Pﬁzer Patient Assistance Foundation is a separate legal entity

from Pﬁzer Inc with distinct legal restrictions.

Click here for XELJANZ full Prescribing Information, including BOXED WARNING and Medication Guide.

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

Address:

City: State: ZIP Code:

SHIP TO

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

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.

HCP TO COMPLETE

PFIZER PATIENT ASSISTANCE PROGRAM

CLINICAL AND

PRESCRIPTION

INFORMATION

Patient First Name: Patient Last Name:

Patient Date of Birth: Patient Phone:

Rx: XELJANZ XR 11 mg PO QD, 30-day supply XELJANZ 10 mg PO BID, 30-day supply XELJANZ 5 mg PO BID, 30-day supply

XELJANZ XR is not recommended in UC. 10 mg is recommended only in UC.

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:

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HIPAA Authorization Form for the Disclosure of Patient Information

by Personal Physician

FOR PFIZER INC AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC.

DO NOT SUBMIT THIS FORM WITH YOUR APPLICATION—IT IS FOR

PATIENT AND PRESCRIBER RECORDS ONLY

To the Patient: Pzer Inc and the Pzer Patient Assistance Foundation, Inc., offer

patient assistance programs (the “Program”) to help patients who qualify obtain certain

Pzer medicines at no cost. In order to determine your eligibility for the Program and to

administer your participation in the Program if you are accepted, Pzer, along with its

afliated companies and contractors who administer the Program, need to obtain certain

information about you from your physician (who is also called your “Doctor” in this form).

Please complete this Authorization, sign and date it, and return it to your doctor.

To the Physician: Please retain the original signed Authorization with the patient’s

records and provide a copy to the patient. You do not need to return this patient

Authorization to Pﬁzer.

I request and authorize my Doctor, ___________________________________ , to give

Pzer Inc, including representatives and contractors who work on behalf of Pzer in this

Program (collectively, “Pzer”), my protected health information, including but not limited

to information about my medical condition and treatments, which is necessary to

determine my eligibility for the Program and for my continuing participation in the

Program if I am accepted, to administer the Program, to account for my withdrawal if I

decide to stop participating in this Program, and to evaluate patient satisfaction and the

Program’s overall effectiveness. The type of information that can be given under this

authorization may include:

• My name and birth date

• My address and telephone number

• My social security number

• Financial information about me

• Information about my health benets or health insurance coverage

• Information on my medical condition, as necessary

XELSOURCE

Answers and Support

Click here for XELJANZ full Prescribing Information, including BOXED WARNING and Medication Guide.

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I understand that I may refuse to sign this authorization and that it is strictly voluntary.

Further, I understand that my Doctor may not condition the provision of my treatment on

my signing this authorization.

I know that I can cancel (revoke) this authorization at any time by writing to my Doctor

at __________________________________________________________________. If I cancel

this authorization, then my Doctor will stop providing Pzer, and its representatives, with

information about me. However, I cannot cancel actions that have already been taken by

relying on my authorization.

I understand that once my Doctor gives Pzer information about me based on this

authorization, federal privacy laws may not prevent Pzer from further disclosing my

information. I also understand that signing this authorization does not guarantee that

I will be accepted into a Pzer patient assistance program.

This authorization will expire one (1) year after the date it is signed, below, or one (1) year

after the last date I receive medicines under the Program, whichever is later, or as

required by state law.

Patient or Personal Representative of Patient {If personal representative, indicate

authority to sign on behalf of Patient (if applicable)}

Signature

Date

Name (please print)

Please return the signed form to your Doctor. You are entitled to a copy for

your records.

XELSOURCE

Answers and Support

Click here for XELJANZ full Prescribing Information, including BOXED WARNING and Medication Guide.

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Fillable PFIZER PATIENT ASSISTANCE PROGRAM

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