Get Patient Assistance Program

This guide provides clear and comprehensive instructions on how to fill out the Patient Assistance Program form online. By following these steps, you will ensure that your application process is smooth and efficient.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Starting with the form, please print clearly in the shaded areas. Begin by selecting the appropriate Pfizer product from the options listed on the form.
3. Fill in the patient’s name, sex, address, city, state, zip code, and phone numbers for both day and evening contacts. Be sure to include the date of birth.
4. Indicate if the Tropism assay has been completed by selecting 'Yes' or 'No'.
5. For the insurance information section, provide details regarding the patient's insurance policies. Specify whether the patient has insurance and fill in the primary insurance company’s name, policy holder's information, and necessary policy details.
6. Complete the Patient Financial Information section by stating the total number of people within the household and the total annual income. Attach relevant income proof documentation as required.
7. Read the Patient Declaration carefully, and if in agreement, sign the form to affirm that the information provided is accurate. If the patient is under 18, a parent or guardian should sign.
8. Finally, save your changes, download, or print the filled-out form for your records or to submit it. If necessary, share it as required for the assistance program.

Complete your Patient Assistance Program application online today for prompt assistance.