Xelsource Enrollment Form

Xelsource Enrollment Form - Complete print and fax to enroll patients in XELSOURCE Download Now Loading e Platform Enrollment Form Complete print and fax to register for XELSOURCEportal Download Now Loading XELSOURCE Prescription and Enrollment Form Complete print and fax to enroll patients in XELSOURCE

Please complete the form where applicable and return via mail or fax Please return all pages to XELSOURCE Check here if reapplying for the Pfizer Patient Assistance Program XELSOURCE SMS PROGRAM OPT IN By checking this box and providing my cellular number I consent to receive enrollment

Xelsource Enrollment Form

Xelsource Enrollment Form

prescription information and xelsource enrollment form Please complete and fax this form, along with a fax cover sheet, to 1-866-297-3471. For assistance or additional information, call 1-844-XELJANZ (1-844-935-5269), Monday–Friday, 8 AM–8 PM ET

Use this portal to Access forms resources Enroll in co pay savings program Electronically sign documents View latest program status updates Receive patient support

PFIZER PATIENT ASSISTANCE PROGRAM

Phone 1 844 XELJANZ 1 844 935 5269 Fax 1 866 297 3471 2730 S Edmonds Lane Suite 300 Lewisville TX 75067 Please complete the form where applicable and return via mail or fax Pages 1 and 3 must be returned to XELSOURCE Check here if reapplying for the Pfizer Patient Assistance Program

Xelsource Patient Assistance Enrollment Form Form Resume Examples jP8JDZz5KV

Prescription Information and XELSOURCESM Enrollment Form Please complete and fax this form to 1 866 297 3471 For assistance or additional information call 1 855 4 XELJANZ 493 5526 Monday Friday 8 am 8 pm ET 1 PATIENT INFORMATION NAME First MI Last DOB MM DD YYYY GENDER ADDRESS CITY STATE ZIP CODE HOME

XELSOURCE XELJANZ 174 Tofacitinib Safety Info

Forms Resources Assisting with access and Affordability for patients prescribed Xeljanz tofacitinib Use this Healthcare Provider HCP E Platform to Enroll patients into XELSOURCE Request an electronic benefits investigation Access financial options for eligible patients

Otezla Enrollment Form Enrollment Form

Ready to fill your XELJANZ prescription See where you are in the process To speak to someone at XELSOURCE about your insurance coverage and XELJANZ costs Monday through Friday 8 00 AM 8 00 PM ET call 1 844 935 5269 and say Representative 1 844 935 5269 MONDAY FRIDAY 8 00 AM 8 00 PM ET Financial Support Options

PRESCRIPTION INFORMATION AND XELSOURCE ENROLLMENT FORM. FOR USE WITH RHEUMATOID ARTHRITIS OR PSORIATIC ARTHRITIS PATIENTS ONLY. Please complete and fax this form, along with a fax cover sheet, to 1-866-297-3471. For assistance or additional information, call 1-844-XELJANZ (1-844-935-5269), Monday–Friday, 8 AM–8 …

PRESCRIPTION INFORMATION AND XELSOURCE

Patient Portal You will be directed to another XELSOURCE site to complete your online application without creating an account However you are encouraged to register for an improved experience including Re enroll in the Pfizer Patient Assistance Program View program status Send messages and upload documents

Xelsource Enrollment Form

Ready to fill your XELJANZ prescription See where you are in the process To speak to someone at XELSOURCE about your insurance coverage and XELJANZ costs Monday through Friday 8 00 AM 8 00 PM ET call 1 844 935 5269 and say Representative 1 844 935 5269 MONDAY FRIDAY 8 00 AM 8 00 PM ET Financial Support Options

Please complete the form where applicable and return via mail or fax Please return all pages to XELSOURCE Check here if reapplying for the Pfizer Patient Assistance Program XELSOURCE SMS PROGRAM OPT IN By checking this box and providing my cellular number I consent to receive enrollment

Xelsource Patient Assistance Form Form Resume Examples l6YN7NO4V3