SOMAVERT (pegvisomant for injecion)
Understanding AcromegalyControlling IGF-1About SomavertFor Patients on SOMAVERTPfizer Bridge ProgramFAQs

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.