Enrollment Form for Group C Medicines

Current 1. Eligibility
2. Vaccine Approval Number
3. Patient Information
4. Patient Privacy Statement
5. HIPAA Authorization Form
6. Prescriber Information
7. Vaccine Information
8. Prescriber Privacy Statement
9. Download Form

STEP 1 OF 9

Who Is This Form For?

This enrollment form is for Prescribers who have uninsured patients who need help paying for Prevnar 13^® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM 197 Protein]) and/or Trumenba^® (Meningococcal Group B Vaccine). Through the Pfizer Patient Assistance Program, Prescribers' purchased stock of the vaccine is replenished when administered to eligible patients approved for assistance.

Does your patient qualify for vaccine replacement?

To be eligible for assistance, your patient must:

Have no insurance or prescription coverage for the vaccine needed
Reside in the United States
Meet certain age requirements:
- Prevnar 13^®: Be at least 18 years of age
- Prevnar 20™: Be at least 18 years of age
- Trumenba^®: Be between 19 and 25 years of age

If you need immediate assistance with your Group C medicine, please call 1-866-706-2400.

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation^TM. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions.