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XELSOURCE Patient Assistance Program Application

1 Phone 1- 84 4-XELJANZ (1-844-935-5269) Fax 1-866-297-3471 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067 Patient Declaration By signing below, I affirm that my answers and my proof-of-income documents are complete, true, and accurate to the best of my understand that: Completing this Application form does not guarantee that I will qualify for the Pfizer Patient Assistance Program . Pfizer may verify the accuracy of the information I have provided and may ask for more financial and insurance information. Any medications supplied by the Pfizer Patient Assistance Program shall not be sold, traded, bartered, or transferred. Pfizer reserves the right to change or cancel the Pfizer Patient Assistance Program at any time. The support provided in this Program is not contingent on any future certify and attest that if I receive medicine(s) provided by the Pfizer Patient Assistance Program : I will promptly contact XELSOURCE if my financial status or insurance coverage changes.

the pregnant mother and her baby. If you are pregnant or become pregnant while taking XELJANZ/XELJANZ XR, talk to your healthcare provider about how you can join this pregnancy registry or you may contact the registry at 1-877-311-8972 to …

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