Pfizer I&I HCP Enrollment Microsite

Brand*:

Please confirm the following eligibility questions:

I confirm that I am not licensed to practice medicine in the state of Vermont.
I confirm that I am not an Advance Practice Registered Nurse ("APRN") engaged in an independent practice in the state of Connecticut.

By checking this box I confirm I agree to the above points.

HCP Information

Name of HCP Office*:

NPI*:

Patient Demographics

First Name*:

Last Name*:

Date of Birth*:

Address1*:

Address2:

City*:

State*:

Zip Code*:

Phone:

Email:

Preferred Method of Communication*:

Caregiver Info

Caregiver info must be provided if patient is under 18 years old

Is address the same as the patient?

Yes No

First Name*:

Last Name*:

Address1*:

Address2:

City*:

State*:

Zip Code*:

Date of Birth*:

Attestation Questions

Pfizer I&I Co-Pay Patient Savings Program Eligibility Requirements. Patients Attest to the Following:

Do you have insurance from any Federal Healthcare Program (including Medicare, Medicaid, Tricare, or any other state or federal medical Pharmaceutical benefit program or pharmaceutical assistance program)?
Yes No

Are both you and your partner over 65 years of age and retired?
Yes No

Do you receive Social Security Disability Insurance (SSDI) or any other Social Security Administration (SSA) benefit?
Yes No

Do you receive insurance from the military?
Yes No

Read the following Privacy Statement to the patient:
Pfizer understands that your personal and health information is private and will only use your information in accordance with our Privacy Policy www.pfizer.com/privacy. The information you provide will only be used by Pfizer and parties acting on its behalf to send you the materials you requested as well as other helpful product and/or related product information, disease state information, offers, and services.
I have read the above privacy statement.
Yes No

Excluded Conditions for Abrilada

The Prescribing Information for Abrilada™ does not include adolescent hidradenitis suppurativa (HS), pediatric uveitis, or pediatric ulcerative colitis. Support is not available for patients prescribed Abrilada™ to treat these conditions.

Please check here to confirm the patient does not have these conditions.