The Connection to Care application form is divided into two sections: one for the physician and one for the patient.

The physician is responsible for completing the healthcare provider information and providing a signed prescription.

Patients are responsible for completing their portion of the application and enclosing their financial documents.

Patients must then mail in the application along with their prescription and income information.

Pfizer will review the application and accompanying documents to determine if eligibility requirements have been met.

Either an acceptance or denial letter will be mailed to both the patient and the physician.

If the request is approved, the medication will be provided free of charge.

Generally, a three-month supply is sent to the physician's office.

It is then up to the physician to contact the patient to pick up the filled prescription.

Application Requirements for Physicians

• Physicians must attach an original signed prescription.
• Physicians need to provide their DEA and/or state license number.
• Physicians must sign the application form.
• Physicians may photocopy the application, but original signatures are required.

Application Requirements for Patients

• Single household income must be $19,000 or less; if married, household income must be $31,000 or less.
• Patients must not have any prescription drug coverage through private insurance or any public assistance programs.
• Patients must submit a copy of their tax return and financial documentation to verify eligibility only once per year, but they need to reapply for medications every three months.
• Patients must mail in the completed application and supporting