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
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.
Contact the Joint Effort patient support program at 1-888-748-8926.
Amgevita
Contact the Amgevita Enliven patient support program at 1-877-936-2735
Avsola
Contact the Avsola Enliven patient support program at 1-877-936-2735
Benlysta
Benlysta (belimumab) Monarch Program for patients:
Contact the Benlysta Monarch support program at 1-855-788-3135.
Brenzys
Brenzys (etanercept) support program form:
Contact the Harmony patient support program at 1-866-556-5663.
Cimzia
Cimzia (certolizumab) Solutions support program:
Contact the Cimzia Solutions patient support program at 1-800-908-5555.
Cosentyx
Cosentyx (secukinumab) XPOSE patient support program:
Contact the Xpose patient support program at 1-844-27XPOSE (1-844-279-7673).
Enbrel
Enbrel (etanercept) Enliven enrolment form:
Contact the Enliven patient support program at 1-877-936-2735.
Erelzi
Erelzi (etanercept) XPOSE enrolment form:
Contact the XPOSE patient support program at 1-844-279-7673.
Humira
Humira (adalimumab) AbbVie Care patient program enrolment form:
Contact the AbbVie Care patient support program at 1-866-848-6472.
Idacio
Contact the Idacio KabiCare patient support program at 1-888-304-2034
Inflectra
Inflectra (infliximab) for Rheumatoid Arthritis patient support program.
Contact the Inflectra patient support program at 1-844-466-6627.
Kevzara
Kevzara (sarilumab) support program form:
Contact the Mobilize patient support program at 1-888-972-6634.
Olumiant
Olumiant (baricitinib) Patient Support Program consent and enrolment form:
Orencia
Orencia (abatacept) Response Program consent and enrolment form:
Contact the Orencia Response patient support program at 1-877-979-3200.
Otezla
Otezla (apremilast) ezStart Program consent and enrolment form:
Contact the Otezla ezStart patient support program at 1-844-397-5635.
Remicade
Remicade (infliximab) Bioadvance enrolment form:
Renflexis
Renflexis (infliximab) Merck Harmony enrolment form:
Contact the Merck Harmony patient support program at 1-866-556-5663.
Rituxan
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.
Riximyo
Contact the Riximyo XPose patient support program at 1-888-449-7673.
Ruxience
Contact the Pfizer Flex patient support program at 1-855-935-3539.
Simponi
Simponi (golimumab) Bioadvance enrolment, Rx, and consent forms:
Taltz
Taltz (ixekizumab) Enrolment Form:
Contact the LillyPlus patient support program at 1-877-219-8908.
Tremfya
Tremfya Bioadvance Enrolment Form:
Xeljanz
Xeljanz (tofacitinib) eXel Program Enrolment Form:
Contact the eXel patient support program at 1-855-XEL-EXEL (1-855-935-3935).