SOMAVERT (pegvisomant for injecion)
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Patient Authorization Forms

Patient Authorization Form

This form authorizes the Pfizer Bridge Program to use your patient's personal health information. At the time your patient is prescribed GENOTROPIN, download and print this form and give it to the patient or caregiver to review and sign; then fax it back to us along with the SMN.

Patient Representative Amendment to the Patient Authorization

The Patient Representative Amendment to the Patient Authorization was created to give the patient/caregiver the opportunity to identify additional "advocates" to act on their behalf, other than those included in their original Patient Authorization Form. This form will be provided to the patient/caregiver by the Pfizer Bridge Program, if requested, to allow information about the patient to be shared with the party identified on the form. As with the Patient Authorization form, at the time your patient is prescribed GENOTROPIN, download and print this form and give it to the patient or caregiver to review and sign; then fax it back to us along with the SMN.

Your PCC can provide the above forms directly to your patients if you prefer.