Patient Authorization Forms
Both the Patient Authorization Form and the Patient Representative Amendment to
the Patient Authorization should be signed then mailed or faxed to us. You can mail
it to: Pfizer Bridge Program™, P.O. Box 220746, Charlotte, NC 28222-0746.
Or you can fax it to 1-800-479-2562. If you have questions about this form, please
call your Patient Care Consultant at the Pfizer Bridge Program at (800) 645-1280.
Patient Authorization Form
This form gives the Pfizer Bridge Program permission to use your personal health
information. We need this information in order to help you. If you have not already
submitted the form to your doctor's office, you can download it here, print it out, and then send it in to us.
Patient Representative Amendment to the Patient Authorization
The Patient Representative Amendment to the Patient Authorization allows
you, the patient/caregiver, to identify additional "advocates" to act on your/their
behalf, other than those included on the original Patient Authorization Form. As
with the Patient Authorization form, you can download it here and print it out then send it in to us.