Home
Forms Library
Xelsource patient assistance application 2024 pdf

Get the up-to-date xelsource enrollment form 2022-2025 now

xelsource patient assistance application 2024 pdf Preview on Page 1

Show details

4.4 out of 5

32 votes

The document is a Prescription Information and XELSOURCE Enrollment Form for adult patients with ulcerative colitis, detailing the process for requesting benefits investigation and prescription fulfillment for XELJANZ (tofacitinib). It includes sections for patient information, insurance details, clinical information, prescriber information, and patient authorization. The document also outlines important safety information regarding the use of XELJANZ, including risks of serious infections, malignancies, gastrointestinal perforations, and laboratory abnormalities. Additionally, it provides terms and conditions for trial and interim care prescription programs.

Here's how it works

01. Edit your xelsource patient assistance application 2024 pdf online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send xelsource enrollment form pdf via email, link, or fax. You can also download it, export it or print it out.

How to quickly redact Xelsource enrollment form 2022 online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Dochub is the greatest editor for modifying your paperwork online. Follow this straightforward instruction to edit Xelsource enrollment form 2022 in PDF format online free of charge:

Sign up and sign in. Register for a free account, set a strong password, and go through email verification to start managing your templates.
Upload a document. Click on New Document and select the form importing option: upload Xelsource enrollment form 2022 from your device, the cloud, or a protected URL.
Make adjustments to the template. Take advantage of the upper and left-side panel tools to modify Xelsource enrollment form 2022. Insert and customize text, pictures, and fillable fields, whiteout unnecessary details, highlight the important ones, and comment on your updates.
Get your paperwork accomplished. Send the form to other parties via email, generate a link for quicker file sharing, export the template to the cloud, or save it on your device in the current version or with Audit Trail added.

Explore all the advantages of our editor today!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get help paying for Xeljanz?

Sign up for the XELJANZ Co-Pay Savings Program, if Eligible If you are unable to confirm your eligibility or have additional questions, call XELSOURCE at 1-844-935-5269. For eligible underinsured or uninsured patients, XELSOURCE may offer financial assistance through the Pfizer Patient Assistance Program.

How much is Xeljanz without insurance?

Zolinza - Merck Patient Assistance Program This private and confidential program provides medicine free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines.

What is xelsource?

XELSOURCE: Committed to Providing Patients Prescribed XELJANZ with Access Support. XELSOURCE can help eligible XELJANZ patients get started with their treatment and support them along the way, including: Help with Benefit Investigation.

Who is eligible for the patient assistance program?

Eligibility and enrollment Be a US citizen or legal resident. Have a total household income at or below 400% of the federal poverty level. Must be uninsured, or have Medicare. Note: if you have private or commercial insurance, you are not eligible for the PAP.