Pfizerhelpfulanswers.com

EnrollEd PatiEnt rE-ordEr Form
For HEaltHCarE ProFESSional USE onlY
do not USE tHiS Form UnlESS PatiEnt HaS alrEadY
BEEn aPProVEd For tHE PFiZEr ConnECtion to CarE Program
Please fill out the form below and fax to 866-470-1748
or place your order via our automated system by calling 866-706-2400.
PatiEnt inFormation
Patient name:
Patient address:
City:
Zip Code:
telephone:
date of Birth: (mm/dd/YY):
mEdiCation ordEr (90-day Supply)
For Refills / New Orders / Change To Existing Medications, except Lyrica® (pregabalin).
For all controlled substances original prescription pad MUST be used (e.g. Lyrica®). Please attach to this sheet.
Product name:
Strength:
Product name:
Strength:
Product name:
Strength:
For lYriCa® onlY
Complete the following and attach original prescription to this sheet.
allergies: No Known Allergy
Health Conditions:
Prescription and over-the-counter medications:
SHiPPing inFormation (Physician’s Shipping Address)
Physician name:
dEa # or State license #:
Exp. date:
office / Ship-to address:
Zip Code:
office telephone: (
office Fax: (
E-mail address (optional):
By signing below, you, the healthcare provider, understands and agrees to the following:
• Receive and secure patient’s medication at your office until dispensed to your patient.
• Comply with and abide by my State Practitioner Dispensing Laws for authorized Healthcare Providers. • Any medications supplied by Pfizer as a result of this order form are for the use of the patient named on this form only, and shall not be sold, traded, bartered, transferred, returned for credit, or submitted to any third party (such as Medicare, Medicaid or other benefit provider) for reimbursement. • Pfizer may contact the patient directly to confirm receipt of medications. • Pfizer may change or cancel this program at any time. • The medicine will be provided only to this eligible and specific enrolled patient at no charge of any kind. • If a patient is applying for a Hardship Exception, I certify that this medication order or attached controlled substance prescription is medically indicated for this patient, and I will be supervising the patient’s treatments. To the best of my knowledge, this patient would not be able to obtain this medicine without assistance from Connection to Care for the reasons the patient has indicated in this application.
original Signature of
Healthcare Provider:
Connection to Care is part of Pfizer Helpful Answers®, a joint program of Pfizer Inc and the Pfizer Patient Assistance Foundation.™

Source: http://pfizerhelpfulanswers.com/files/C2C_Enroll.pdf