Read RSVPEnrollmentForm_rev5HIPPA.pdf text version

enrollment form: patient application

please complete the form where applicable and return via mail or fax.

phone 1-888-327-7787 or fax 1-888-773-0121

please check the appropriate pfizer product: Zyvox ® (linezolid) rapamune® (sirolimus) revatio ® (sildenafil) elelyso® (taliglucerase alfa) patient name: patient address: city: telephone (Day):

po Box 220574, charlotte, nc 28222-0574

Xyntha® antihemophilic factor (recombinant), plasma/albumin-free BenefiX® coagulation factor iX (recombinant) Vfend ® (voriconazole) tygacil® (tigecycline) (Reimbursement Services Only) Sex: e-mail: State: (evening): Zip code: Male Female

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Date of Birth (DoB):

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YesNo

U.S./puerto rico/U.S.V.i. resident:

inSUrance information (include all insurance policies) Do you have insurance? Yes no (If yes, complete the information below or attach a photocopy of insurance card) primary insurance co. name: policy Holder name: policy Holder SSn: policy #: Secondary insurance co. name: policy Holder name: policy Holder SSn: policy #:

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effective Date:

) policy Holder DoB:

phone #: policy #:

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prescription card name:

phone #: phone #:

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Group #:

Group #:

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effective Date:

) policy Holder DoB:

policy #: phone #:

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prescription card name:

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Group #:

Group #:

patient financial information total number of people Within Household (including applicant): total annual income for entire Household: $ (The current annual household income includes current annual salary, Social Security, unemployment insurance benefits and workers' compensation) please submit documentation to support the financial information attached is: most recent federal tax return (1040 form) W-2 form other

Wemustreceiveproofofincometodetermineeligibilityforassistance. Ifyouarerequiredtofileafederaltaxreturn,pleaseprovideasignedcopy.Proofofincomemayincludedocumentssuchas:copyof mostrecentfederaltaxreturn,W-2form(s),1099form,SocialSecurityAwardLetterorCheck,orcopyofthreemostrecentpaystubs.

patient Declaration ­ Bysigningbelow,Iaffirmthatmyanswersandmyproof-of-incomedocumentsarecomplete,trueandaccuratetothebestofmyknowledge. I understand that: · CompletingthisapplicationformdoesnotguaranteethatIwillqualifyfortheRSVPProgram. · PfizermayverifytheaccuracyoftheinformationIhaveprovidedandmayaskformorefinancialandinsuranceinformation. · AnymedicationssuppliedwiththeRSVPProgramshallnotbesold,traded,barteredortransferred. · PfizerreservestherighttochangeorcanceltheRSVPProgramatanytime. · Thesupportprovidedinthisprogramisnotcontingentonanyfuturepurchase. I certify and attest that if I receive medicine(s) provided by Pfizer through the RSVP Program: · IwillpromptlycontacttheRSVPProgramifmyfinancialstatusorinsurancecoveragechanges. · Iwillnotseektohavethemedicine(s)oranycostfromit(them)countedinmyMedicarePartDout-of-pocketexpensesforprescriptiondrugs. · Iwillnotseekreimbursementorcreditforanycostsassociatedwiththemedicine(s)frommyprescriptioninsuranceproviderorpayor, includingMedicarePartDplans. · Iwillnotifymyinsuranceproviderofthereceiptofanymedicine(s)throughtheRSVPProgram. the information you provide will be used by pfizer, the pfizer patient assistance foundation and parties acting on their behalf to determine eligibility, to manage and improve pfizer Helpful answers (pHa) programs, products and services, to communicate with you about your experience with pHa and the rSVp program, and/or to send you materials and other helpful information and updates relating to pHa programs.

patient Signature

PHA00424H

(Parent or Guardian, if under 18 years of age) X

©2012PfizerInc.

Date:

PrintedinUSA/May2012

enrollment form: HealtHcare proViDer application

please read all information and print clearly. preScriBer information (To be completed by the provider)

prescriber name & title:

payer Specific #: State license #: contact name: name of facility: facility address: city: Ship to: phone: State: tax iD #: Dea #:

npi #:

Zip code:

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prescriber

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patient

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other (please provide shipping address): fax:

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prescriber e-mail address: please provide diagnosis and specific icD-9 code:

prescriber Specialty:

preScriBer certification Icertifythattheinformationprovidediscurrent,complete,andaccuratetothebestofmyknowledge.IwillnotifyRSVPimmediatelyifthe Pfizerproductisnolongermedicallynecessaryforthispatient'streatment.i certify that the pfizer product is medically necessary for this patient and i will be supervising the patient's treatments.IcertifythatIhaveobtainedfrommypatientallrequiredwrittenauthorizationfor thereleaseofmypatient'spersonalidentificationandinsuranceinformationtoPfizerandtheiragentsandrepresentatives.Iunderstandthat anyinformationprovidedisforthesoleuseofPfizerandtheiragentsandrepresentativestoverifymypatient'sinsurancecoverage,toassess,if applicable,patient'seligibilityforparticipationinthepatientassistanceprogramandtootherwiseadministertheRSVPprogramandrelated services.Iunderstandthatapplicationtothepatientassistanceprogramdoesnotguaranteethatassistancewillbeobtained.Iunderstandthat Pfizermaychangeorcancelthisprogramatanytime.Iunderstandthatifmypatient'sfinancialand/orinsurancestatuschanges,thepatient maynolongerbeeligibleforthepatientassistanceprogram,andIagreetoimmediatelynotifyaRSVPrepresentativeifIbecomeawareof changesinthepatient'sinsurancestatus.IagreethatRSVPmaycontactmeforadditionalinformationrelatingtothisapplicationeitherbyfax oranyotherformofcommunication,includingbutnotlimitedtoe-mailandtelephone.IunderstandthatIamundernoobligationtoprescribe anyPfizerproductandthatIhavenotreceivednorwillIreceiveanybenefitfromPfizerortheiragentsorrepresentativesforprescribinga Pfizerproduct.IagreethatIwillnotsubmitclaimsforproductprovidedbythePatientAssistanceProgram. the information you provide will be used by pfizer, the pfizer patient assistance foundation and parties acting on their behalf to administer and improve pfizer Helpful answers (pHa) programs, products, and services, to communicate with you about your experience with pHa and the rSVp program, and/or to send you materials and other helpful information and updates relating to pHa programs.

prescriber Signature:

X

Date:

preScription (This prescription form is not needed for Zyvox. For full prescribing information, go to www.pfizer.com) first name: Date of Birth: Directions: Drug allergies: Yes No if yes, please specify: rapamune: .5mg,90daysupply rapamune: 2mg,90daysupply rapamune: 1mg,90daysupply rapamune oral Solution: 1mg elelyso: Totaldose unitsevery weeks,28daysupply BenefiX coagulation factor iX Monthlydosage: IU Vfend: 50mg,60daysupply Vfend: 200mg,60daysupply revatio: 20mg,90daysupply

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last name: phone #:

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refills:

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times

Xyntha antihemophilic factor, plasma/albumin-free 250IU 500IU 1,000IU 2,000IU

prescribing physician: prescriber Signature: transplant type: transplant facility: X Date: Date of transplant: medicare approved facility: Yes no

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tranSplant HiStorY (For Rapamune Only, Complete Transplant History)

please fax completed prescription form to rSVp at (888) 773-0121. thank You. prescription valid for one year.

PHA00424H ©2012PfizerInc. PrintedinUSA/May2012

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