Medicine Change Request Form PDF Details

In navigating the complexities of patient care, healthcare providers often find themselves at the intersection of clinical decision-making and the practicalities of ensuring that patients have access to prescribed medications. The Medicine Change Request Form, designated for enrolled patients and strictly for prescriber use only, embodies this crossroad, facilitating the addition of new medications or modifications to existing prescriptions within the framework of Pfizer's Connection to Care patient assistance program. This comprehensive form requires detailed patient information, including name, contact details, and medical background, alongside the specific medicine adjustments being requested. It emphasizes the necessity for prescribers to meticulously fill out and fax the document to a designated number, ensuring that patient care remains uninterrupted and tailored. For medications like Lyrica® or for residents of Puerto Rico and U.S. Virgin Islands, the form stipulates additional instructions, highlighting the nuanced approach required in varying circumstances. By requiring the prescriber’s signature, the document also underscores the legal and ethical responsibilities of healthcare providers in managing patient medication, including securing the medication until it can be dispensed and adhering to state laws. Pfizer’s stipulation that medications supplied as a result of this form are strictly for the named patient, prohibiting sale or transfer, further aligns with ethical guidelines and legal requirements. In essence, this form plays a pivotal role in bridging patient needs with pharmaceutical access, aligned with Pfizer's broader commitment to patient assistance, thereby embodying the collaborative essence of modern healthcare provision.

QuestionAnswer
Form NameMedicine Change Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespfizer patient assistance medicine change request form, zer, needymeds, Prescribers

Form Preview Example

MEDICINE CHANGE REQUEST FORM

FOR ENROLLED PATIENTS

FOR PRESCRIBER USE ONLY

Use to add a new medicine, or make a change to an existing medicine, for enrolled Connection to Care patients.

PLEASE FILL OUT THE FORM BELOW AND FAX TO 866-470-1748

PATIENT INFORMATION

 

 

Patient Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

Patient Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

–

 

 

 

 

 

 

Date of Birth: (MM/DD/YY):

 

 

 

 

/

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please indicate the medicine(s) that you wish to add, or change the dosage for, below. Please complete this section for all

 

 

products for U.S. residents, except Lyrica® (pregabalin). For Lyrica® or residents of Puerto Rico and U.S. Virgin Islands,

 

 

please see section C below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Product Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strength:

 

 

Directions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check One):

 

Add

 

 

Dosage Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Product Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strength:

 

 

Directions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check One):

 

Add

 

 

 

Dosage Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Product Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strength:

 

 

Directions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check One):

 

Add

 

 

 

Dosage Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber Signature: To place ongoing medicine re-orders, visit our Provider Portal at www.PfizerPAP.com, or call 855-742-7497.

This is only valid for use with the Pfizer Connection to Care patient assistance program.

C

PATIENT PHARMACY INFORMATION

For Lyrica¨ and patients residing in Puerto Rico and U.S. Virgin Islands, complete this section and attach original prescription. Please include a copy of your patientÕs valid government issued photo ID for new Lyrica¨ prescriptions.

Is the patient allergic to any medications?

 

No

 

Yes

If yes, please list all:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all prescription and over-the-counter medications the patient is currently taking:

D

Prescriber Name:

DEA #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State License #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ship-to Address (No P.O. Box):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suite #:

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

E-Mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OfÞce Telephone:

(

 

)

 

 

 

 

 

–

 

 

 

 

 

 

 

 

OfÞce Fax:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

By signing below, you, the Prescriber, understands and agrees to the following:

•Receive and secure patient’s medication at your office until dispensed to your patient.

•Comply with and abide by my State Practitioner Dispensing Laws for authorized Prescribers.

•Any medications supplied by Pfizer as a result of this order form are for the use of the patient named on this form only, and shall not be sold, traded, bartered, transferred, returned for credit, or submitted to any third party (such as Medicare, Medicaid or other benefit provider) for reimbursement.

•Pfizer may contact the patient directly to confirm receipt of medications.

•Pfizer may change or cancel this program at any time.

•The medicine will be provided only to this eligible and specific enrolled patient at no charge of any kind.

•I have a signed copy on file of my patient’s current and completed HIPAA Authorization Form so that I may share patient health information with the Connection to Care program, Pfizer Inc., and the Pfizer Patient Assistance Foundation Inc.

Original Signature of Prescriber

X

Date:

Connection to Care is part of the Pfizer Helpful Answers® family of patient assistance programs – a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™.

Pfizer Connection to Care

PO BOX 66585

 

ST. LOUIS, MO 63166-6585

PHA472118

© 2012 Pfizer Inc.

Printed in USA/June 2012

FRMPFI102

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