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 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.

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:

Contact the Enliven patient support program at 1-877-936-2735.

Erelzi XPOSE

Erelzi (etanercept) XPOSE enrolment form:

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.

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.

Orencia Response Program

Orencia (abatacept) Response Program consent and enrolment form:

Contact the Orencia Response patient support program at 1-877-979-3200.

Remicade Bioadvance

Remicade (infliximab) Bioadvance enrolment form:

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:

Xeljanz eXel – RA

Xeljanz (tofacitinib) for Rheumatoid Arthritis Enrolment Form:

Contact the eXel patient support program at 1-855-XEL-EXEL (1-855-935-3935).