Xelsource Patient Assistance Form

Xelsource Patient Assistance Form - Please complete the form where applicable and return via mail or fax Pages 1 and 2 must be returned to XELSOURCE Check here if the patient is reapplying for the Pfizer Patient Assistance Program Note If you are a New York prescriber please attach state prescription form

Welcome to the XELSOURCE Patient Portal Use this portal to Access forms resources Enroll in co pay savings program Electronically sign documents View latest program status updates Receive patient support program progress updates Enroll Re enroll in the Pfizer Patient Assistance Program

Xelsource Patient Assistance Form

Xelsource Patient Assistance Form

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

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

Patient Portal Cardinal Health

Download Patient Access Coordinator PAC Opt In Form Complete print and fax to help patients receive support from a PAC Download Voucher Program Rx Form Complete print and mail or fax this form to write a prescription to get new patients started on their medication Download XELSOURCE Programs Terms Conditions

XELSOURCE Forms Resources XELJANZ XR tofacitinib

Complete reimbursement forms for your office Offer personal or medical advice to patients Give out any Pfizer Patient Assistance Program related patient status updates as subject matter expert in reimbursement access and coverage issues for patients caregivers who opted in for support

XELSOURCE Patient Assistance Program Application

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 Patient Assistance Program Form Form Resume Examples 9x8ra0pd3d

PATIENT ASSISTANCE APPLICATION FOR XELJANZ tofacitinib citrate 5 mg tablets Phone 1 855 4 XELJANZ 1 855 493 5526 Fax 1 866 297 3471 PO Box 951522 Lake Mary FL 32795 1522 Please complete the form where applicable and return via mail or fax Do you have prescription drug coverage Yes No

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 1-855-4-XELJANZ (1-855-493-5526), Monday–Friday, 8 AM–8 PM ET to enroll my patient in the XELSOURCE program. I further authorize …

PATIENT ASSISTANCE PROGRAM APPLICATION Amazon

If you are unable to confirm your eligibility or have additional questions call XELSOURCE at 1 844 935 5269 For eligible underinsured or uninsured patients XELSOURCE may offer financial assistance through the Pfizer Patient Assistance Program Call XELSOURCE to learn more about these programs Terms and conditions eligibility

Xelsource Patient Assistance Form

PATIENT ASSISTANCE APPLICATION FOR XELJANZ tofacitinib citrate 5 mg tablets Phone 1 855 4 XELJANZ 1 855 493 5526 Fax 1 866 297 3471 PO Box 951522 Lake Mary FL 32795 1522 Please complete the form where applicable and return via mail or fax Do you have prescription drug coverage Yes No

Welcome to the XELSOURCE Patient Portal Use this portal to Access forms resources Enroll in co pay savings program Electronically sign documents View latest program status updates Receive patient support program progress updates Enroll Re enroll in the Pfizer Patient Assistance Program

Xelsource Patient Assistance Enrollment Form Form Resume Examples jP8JDZz5KV