Transcription of XELSOURCE Patient Assistance Program Application
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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.
1 Phone 1-844-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 knowledge.
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