XELSOURCE Patient Assistance Program Application
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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