Physician Tools

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.

Hadlima

Hadlima (adalimumab) Organon Harmony Care patient program enrolment form:

Contact the Harmony Care patient support program at 1-866-556-5663

Humira

Humira (adalimumab) AbbVie Care patient program enrolment form:

Contact the AbbVie Care patient support program at 1-866-848-6472.

Hyrimoz

Hyrimoz (adalimumab) XPose patient program enrolment form:

Contact the XPose Program at 1-888-449-7673

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) Organon Harmony enrolment form:

Contact the Organon 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).