Transcription of Pfizer Patient Assistance Program
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Pfizer Patient Assistance Program
If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call : Income limits are subject to change on an annual basis; current limits reflect 2019 Federal Poverty Level of People in Your HouseholdTotal Monthly Income Before TaxesTotal Annual Income Before TaxesLess Than or Equal to $4,163 Less Than or Equal to $5,637 Less Than or Equal to $7,110 Less Than or Equal to $8,583 Less Than or Equal to $10,057 Less Than or Equal to $49,960 Less Than or Equal to $67,640 Less Than or Equal to $85,320 Less Than or Equal to $103,000 Less Than or Equal to $120,680PP-PAT-USA-1066 2019 Pfizer Inc. All rights reserved. Printed in USA/June 2019 PO Box 220574, Charlotte, NC 28222-0574 T: 1-855-239-9869 F: 1-855-998-6951 Pfizer Patient Assistance Program :Instructions for group B Enrollment Form This enrollment form is for patients who would like to apply to receive any of the group B medicines found below for free through the Pfizer Patient Assistance Program .
Enrollment Form for Group B Medicines: PATIENT SECTION The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance FoundationTM. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc. with distinct legal restrictions. Signature of Patient X Date:
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