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Xelsource patient assistance application

Xelsource patient assistance program application 2026

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The document is an application form for the Pfizer Patient Assistance Program, specifically for XELJANZ® XR (tofacitinib) tablets. It requires patients to provide personal and financial information to determine eligibility for assistance in obtaining the medication, which is used to treat rheumatoid arthritis and psoriatic arthritis. The document includes important safety information about potential side effects, risks of serious infections, and guidelines for healthcare providers regarding patient treatment and monitoring.

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Click ‘Get Form’ to open the XELSOURCE Patient Assistance Program Application in the editor.
Begin by filling out the 'Patient Information' section. Enter your name, address, city, state, ZIP code, and contact numbers. Providing an email can expedite the process.
In the 'Insurance Information' section, confirm if you have prescription drug coverage. If not, check the appropriate box and provide details about your household size and total annual income.
For 'Financial Information', attach necessary documentation such as your most recent federal tax return or W-2 forms to support your income claims.
Complete the 'Patient Declaration' by signing and dating the form. Ensure all information is accurate before submission.
Finally, review all sections for completeness and clarity before submitting via mail or fax as instructed on the form.

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