Get Pha537029 01 Pfizer Connection Care Form

This guide provides clear and supportive instructions for successfully completing the Pha537029 01 Pfizer Connection Care Form online. By following these steps, users can ensure that they provide all necessary information to apply for assistance effectively.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online tool.
2. Begin by entering the patient's name and address in the designated fields, ensuring each section is filled out clearly.
3. Provide the patient's email address and phone number. Ensure the contact information is accurate to receive updates regarding the application.
4. Indicate the patient's gender and date of birth in the specified format (MM/DD/YY).
5. Input the total gross annual household income and specify the number of persons in the household, including the applicant.
6. Answer the question regarding whether the applicant has insurance coverage for prescription drugs, selecting 'Yes' or 'No' as applicable.
7. If applicable, complete the hardship assistance section, detailing the type of prescription drug coverage and affirming financial hardship.
8. Review and sign the patient privacy and consent section, affirming that all provided information is true and accurate.
9. After completing the patient section, the prescriber must fill out their portion of the application, which includes medication order information.
10. Compile all required documents, including the completed application form and proof of income documents, to finalize the application.
11. Follow instructions to mail or fax all required documents to the specified address or fax number provided in the application.
12. Be sure to save changes, download, print, or share the filled-out form as needed for record-keeping.

Complete your application today by filling out the Pha537029 01 Pfizer Connection Care Form online.