GET HELP FILLING YOUR PRESCRIPTION FROM A PFIZER ACCESS & REIMBURSEMENT MANAGER (ARM)

When you opt-in for Access & Reimbursement Manager (ARM) support you will be contacted by a Pfizer ARM who can help you understand your insurance benefits and navigate the process to access your prescribed medication. Pfizer ARMs are field-based employees of Pfizer Rare Disease and, if you choose, will help answer questions you may have about accessing the medication prescribed by your Healthcare Provider. Pfizer ARMs are familiar with access and reimbursement requirements, and the Pfizer ARM assigned to you serves as a resource for you on your journey to starting therapy. Working with a Pfizer ARM is optional. By checking this box/signing this form, I request Pfizer ARM support and agree to receive telephonic communications from the Pfizer ARM assigned to my case as described above. I understand that my consent is not required or a condition of purchasing any Pfizer goods or services. I understand that I can opt-out of support from and communications with the Pfizer ARM at any time by informing my assigned ARM that I no longer wish to communicate with them. I understand that this form will remain in effect for one year (ie, 1 year from the date of my signature) unless I opt-out of support from and communications with the Pfizer ARM at any time by informing my assigned ARM that I no longer wish to communicate with them.

Patient authorization date:

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