Printable Form For Pfizer Patient Assistance Program Date Patient Authorization to Share Health Information This must be signed and returned to VelsipityForMe to receive assistance 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 privacy
As of January 1 2024 the Pfizer Patient Assistance Program will be changing Click here for more details Resources For Patients View Resources For Caregivers View Resources For Healthcare Providers Office Staff View Resources With RxPathways Pfizer has been able to make a positive impact for patients 6 3 million Prescriptions The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc with distinct legal restrictions For additional support call 1 844 989 PATH 7284 for New Patients or 1 866 706 2400 for Enrolled PAP Patients
Printable Form For Pfizer Patient Assistance Program
Printable Form For Pfizer Patient Assistance Program
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PAP Connect enables US patients and their healthcare providers to apply and manage their enrollment for select primary care medicines in the Pfizer Patient Assistance Program completely online through their mobile device or computer Privacy notice the pfizer patient assistance foundation respects your right to confidentiality of your personal and medical information the pfizer patient assistance foundation will not share your personal information with outside mailing lists or telemarketers however the pfizer patient assistance foundation and companies that
To be evaluated for assistance patients and their healthcare providers must submit a completed enrollment form Patients must also provide proof of income such as a W2 form a paycheck stub or prior year s tax return The Pfizer Patient Assistance Program is a joint program of Pfizer Inc and the Pfizer Patient Assistance Foundation Pfizer Patient Assistance Program Provides free Pfizer medicines to eligible patients through their doctor s office or at home To qualify patients must Have a valid prescription for the Pfizer medicine available in the PAP for which they are seeking assistance Have an FDA approved indication for the requested product s
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Pfizer RxPathways Patient Assistance Program Enrollment Form for Group A Medicines Gather the following required documents Completed and signed enrollment form pages 3 4 Note Retain the HIPAA form on page 5 for your own records A photocopy of one of the following documents that shows your total annual income Note Include copies of the front and back of your medical and pharmacy insurance cards with your enrollment 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
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 certify that the information provided is current complete and accurate to the best of my knowledge To qualify for free medicine through the Pfizer Patient Assistance Program patients must Seek assistance for a medicine available through the Pfizer Patient Assistance Program for an FDA approved indication Meet income guidelines which vary by product and household size 300 FPL for Primary Care products including Eucrisa and 500 or
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https://velsipityforme.pfizer.com/assets/documents/pp-ipe-usa-0654-52352-id01aa-vel-combined-hcp-patient-pap-app-digital-a-form.pdf
Date Patient Authorization to Share Health Information This must be signed and returned to VelsipityForMe to receive assistance 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 privacy
https://www.pfizerrxpathways.com/
As of January 1 2024 the Pfizer Patient Assistance Program will be changing Click here for more details Resources For Patients View Resources For Caregivers View Resources For Healthcare Providers Office Staff View Resources With RxPathways Pfizer has been able to make a positive impact for patients 6 3 million Prescriptions
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Printable Form For Pfizer Patient Assistance Program - 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
