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.

Actemra Joint Effort for Rheumatoid Arthritis
Actemra Joint Effort for Giant-Cell Arteritis
Actemra Joint Effort for Systemic Juvenile Idiopathic Arthritis

Contact the Joint Effort patient support program at 1-888-748-8926.

Amgevita

Amgevita Enliven Support Program

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

Avsola

Avsola Enliven Support Program

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

Benlysta

Benlysta (belimumab) Monarch Program for patients:

Benlysta Monarch Program Enrolment Form
Benlysta Medical Order Form

Contact the Benlysta Monarch support program at 1-855-788-3135.

Brenzys

Brenzys (etanercept) support program form:

Brenzys Organon Harmony Enrolment Form

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

Cimzia

Cimzia (certolizumab) Solutions support program:

Cimzia Solutions Patient Support Program Enrolment Form

Contact the Cimzia Solutions patient support program at 1-800-908-5555.

Cosentyx

Cosentyx (secukinumab) XPOSE patient support program:

Cosentyx XPOSE Support Program Enrolment Form

Contact the Xpose patient support program at 1-844-27XPOSE (1-844-279-7673).

Enbrel

Enbrel (etanercept) Enliven enrolment form:

Enliven Enrolment Form

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

Erelzi

Erelzi (etanercept) XPOSE enrolment form:

XPOSE Enrolment Form

Contact the XPOSE patient support program at 1-844-279-7673.

Hadlima

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

Hadlima – Organon Harmony Form

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

Humira

Humira (adalimumab) AbbVie Care patient program enrolment form:

Humira – AbbVie Care Form

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

Hyrimoz

Hyrimoz (adalimumab) XPose patient program enrolment form:

Hyrimoz – XPose Form

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

Idacio

Idacio KabiCare Support Program

Contact the Idacio KabiCare patient support program at 1-888-304-2034

Inflectra

Inflectra (infliximab) for Rheumatoid Arthritis patient support program.

Inflectra Enrolment Form

Contact the Inflectra patient support program at 1-844-466-6627.

Kevzara

Kevzara (sarilumab) support program form:

Kevzara Mobilize Enrolment Form

Contact the Mobilize patient support program at 1-888-972-6634.

Olumiant

Olumiant (baricitinib) Patient Support Program consent and enrolment form:

Olumiant Patient Support Program Enrolment Form

Orencia

Orencia (abatacept) Response Program consent and enrolment form:

Orencia Response Program Enrolment Form

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

Otezla

Otezla (apremilast) ezStart Program consent and enrolment form:

ezStart Program Enrolment Form

Contact the Otezla ezStart patient support program at 1-844-397-5635.

Remicade

Remicade (infliximab) Bioadvance enrolment form:

Remicade Bioadvance Enrolment Form

Renflexis

Renflexis (infliximab) Organon Harmony enrolment form:

Renflexis 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):

Rituxan Joint Effort Enrolment Form (RA)
Rituxan Joint Effort Enrolment Form (GPA, MPA)

Contact the Joint Effort patient support program at 1-888-532-1198.

Riximyo

Riximyo XPose Program

Contact the Riximyo XPose patient support program at 1-888-449-7673.

Ruxience

Ruxience Pfizer Flex Enrolment Form (RA)
Ruxience Pfizer Flex Enrolment Form (GPA, MPA)

Contact the Pfizer Flex patient support program at 1-855-935-3539.

Simponi

Simponi (golimumab) Bioadvance enrolment, Rx, and consent forms:

Simponi Bioadvance Forms – Injectable (SC)
Simponi Bioadvance Forms – Intravenous (IV)

Taltz

Taltz (ixekizumab) Enrolment Form:

Taltz LillyPlus Form

Contact the LillyPlus patient support program at 1-877-219-8908.

Tremfya

Tremfya Bioadvance Enrolment Form:

Tremfya Bioadvance Enrolment Form

Xeljanz

Xeljanz (tofacitinib) eXel Program Enrolment Form:

Xeljanz eXel Form

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