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.

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:

Taltz LillyPlus

Taltz (ixekizumab)Enrolment Form:

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

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).