Get Pizer Patient Assistance & Insurance Support Programs

This guide provides step-by-step instructions for completing the Pizer Patient Assistance & Insurance Support Programs enrollment form online. Follow these instructions to ensure a smooth application process and to increase your chances of receiving assistance.

Follow the steps to effectively complete your enrollment form.

1. Click ‘Get Form’ button to obtain the enrollment form and open it for completion.
2. Fill out the patient information section, including your name, address, email, telephone number, date of birth, household size, and total annual income. Ensure that the income documentation is attached.
3. Indicate whether you have prescription coverage. If yes, proceed to fill in the insurance information section including details about your primary and secondary insurance providers.
4. Complete the prescriber section by providing your prescriber's information, and ensure they sign it. This includes the prescriber’s name, NPI number, contact details, and the patient's prescription details.
5. Review the patient privacy and consent section. Carefully read through the statements, then sign and date to certify the information is accurate and that you cannot afford the medication.
6. Gather all required documents, including the completed enrollment form and income verification. Make photocopies for your records, as original documents may not be returned.
7. Submit your application by having the prescriber fax or mail the completed forms to the provided address (Pfizer Patient Assistance & Insurance Support Programs, P.O. Box 66976, St. Louis, MO 63166-6976).
8. Ensure to retain the HIPAA form for your records and await a response regarding your application status.

Begin your application process now by completing the enrollment form online.