Please complete and fax this form to 1-888-878-8474 or complete online at www-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Ensure all fields marked with an asterisk (*) are completed, including your name, date of birth, and contact details.
3. Proceed to the Patient Financial Information section if you are seeking financial assistance. Attach necessary documentation such as your federal tax return or W-2 form.
4. In the Insurance Information section, provide details about your primary insurance. If applicable, include copies of both sides of your insurance and prescription cards.
5. Complete the Patient Consent for Pfizer Patient Assistance Programs. This is required if you entered financial information in section 2.
6. Review and sign the Patient Authorization to Share Health Information in section 7. Make sure to check any optional support programs you wish to enroll in.
7. Once all sections are complete, save your document and fax it to 1-888-878-8474 or submit it online through our platform.

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