Patient Support Program Enrolment Forms
This page features links to download the enrolment forms of a number of Patient Support Programs. These programs are organized by pharmaceutical companies and are intended for patients that have been prescribed their medications.
Actemra Joint Effort – RA, JIA
Actemra (tocilizumab) Joint Effort support program for Rheumatoid Arthritis, Giant-Cell Arteritis, and Systemic Juvenile Idiopathic Arthritis. The form includes sections for both IV and SC Actemra.
- Actemra Joint Effort for Rheumatoid Arthritis (PDF)
- Actemra Joint Effort for Giant-Cell Arteritis (PDF)
- Actemra Joint Effort for Systemic Juvenile Idiopathic Arthritis (PDF)
Contact the Joint Effort patient support program at 1-888-748-8926.
Benlysta Monarch
Benlysta (belimumab) Monarch Program for patients:
Contact the Benlysta Monarch support program at 1-855-788-3135.
Brenzys Harmony
Brenzys (etanercept) support program form:
Contact the Harmony patient support program at 1-866-556-5663.
Cimzia Solutions
Cimzia (certolizumab) Solutions support program:
Contact the Cimzia Solutions patient support program at 1-800-908-5555.
Cosentyx XPOSE
Cosentyx (secukinumab) XPOSE patient support program:
Contact the Xpose patient support program at 1-844-27XPOSE (1-844-279-7673).
Enbrel Enliven
Enbrel (etanercept) Enliven enrolment form:
- Enliven Enrolment Form (PDF)
Contact the Enliven patient support program at 1-877-936-2735.
Erelzi XPOSE
Erelzi (etanercept) XPOSE enrolment form:
- XPOSE Enrolment Form (PDF)
Contact the XPOSE patient support program at 1-844-279-7673.
Humira AbbVie Care
Humira (adalimumab) AbbVie Care patient program enrolment form:
Contact the AbbVie Care patient support program at 1-866-848-6472.
Inflectra Program – RA
Inflectra (infliximab) for Rheumatoid Arthritis patient support program.
- Inflectra Enrolment Form (PDF)
Contact the Inflectra patient support program at 1-844-466-6627.
Kevzara Mobilize Program
Kevzara (sarilumab) support program form:
Contact the Mobilize patient support program at 1-888-972-6634.
Olumiant Patient Support Program
Olumiant (baricitinib) Patient Support Program consent and enrolment form:
Orencia Response Program
Orencia (abatacept) Response Program consent and enrolment form:
Contact the Orencia Response patient support program at 1-877-979-3200.
Otezla ezStart Program
Otezla (apremilast) ezStart Program consent and enrolment form:
Contact the Otezla ezStart patient support program at 1-844-397-5635.
Remicade Bioadvance
Remicade (infliximab) Bioadvance enrolment form:
Renflexis Merck Harmony
Renflexis (infliximab) Merck Harmony enrolment form:
Contact the Merck Harmony patient support program at 1-866-556-5663.
Rituxan Joint Effort – RA, GPA, MPA
Rituxan (rituximab) Joint Effort enrolment forms for Rheumatoid Arthritis, and for Granulomatosis with Polyangiitis (GPA) and Microscopic Polyangiitis (MPA):
Contact the Joint Effort patient support program at 1-888-532-1198.
Simponi Bioadvance
Simponi (golimumab) Bioadvance enrolment, Rx, and consent forms:
Taltz LillyPlus
Taltz (ixekizumab) Enrolment Form:
- Taltz LillyPlus Form (PDF)
Contact the LillyPlus patient support program at 1-877-219-8908.
Xeljanz eXel – RA
Xeljanz (tofacitinib) for Rheumatoid Arthritis Enrolment Form:
- Xeljanz eXel Form (PDF)
Contact the eXel patient support program at 1-855-XEL-EXEL (1-855-935-3935).