Janssen CarePath Patient Authorization
• Patients should read the Patient Authorization and sign electronically or download, print, and sign.
– Completed form may be uploaded to Patient Account or Provider Portal, faxed to Janssen CarePath at 866-836-0567, or mailed
to address below.
• Patients can access a copy of completed form in their Janssen CarePath Account – My Profile.
My signature on this Patient Authorization Form confirms that I authorize each of my physicians, pharmacists, including any specialty pharmacy that
receives my prescription for a Janssen medication, and other healthcare providers (together, “Healthcare Providers”), and each of my health insurers
(together, “Insurers”) to disclose my protected health information, including but not limited to information related to my medical condition and treatment,
my health insurance coverage, my name, address, telephone number, insurance plan and/or group numbers (together, “Protected Health Information”)
to Johnson & Johnson Health Care Systems Inc., its affiliated companies, agents and representatives (together, “Janssen”), including providers of alternate
sources of funding for prescription drug costs, and other approved service providers authorized to manage, administer, and/or support Janssen CarePath
programs, Janssen CarePath Account for Patients, and Provider Portal for their Healthcare Providers for the purposes described below.
Specifically, I authorize Janssen to receive, use, and disclose my Protected Health Information in order to (i) enroll me in, determine my eligibility for, and
contact me about, Janssen medication support programs; (ii) provide me with educational materials, information, and services related to my Janssen
medication; (iii) verify, investigate, assist with, and coordinate my coverage for my Janssen medication with my Insurers; (iv) coordinate prescription
fulfillment; (v) assist with analyses related to the quality, efficacy, and safety of my Janssen medication, and patient access to and adherence to my
Janssen medication; (vi) to share and provide access to information generated by Janssen CarePath that may be useful for my care, and; (vii) to improve,
develop, and evaluate Janssen CarePath, its offerings, and materials. I also understand that pharmacies that ship my medication may be paid to share this
information with Janssen CarePath to help provide the offerings requested for me. Furthermore, I understand that my Protected Health Information will
not be used or disclosed by Janssen for any other purpose without my prior authorization unless permitted by law or unless information that specifically
identifies me is removed. I understand that Janssen will make every effort to keep my information private. Further, I understand that if my information is
accidentally shared, federal privacy laws do not require that the person/party receiving it not disclose the information further and that such information
provided to a third party may no longer be protected by federal privacy laws.
I understand that I am not required to sign this Patient Authorization Form. My choice about whether to sign will not change the way my Healthcare
Providers or Insurers treat me. If I refuse to sign the Patient Authorization Form, or revoke my authorization later, I understand that this means I will not be
able to participate or receive assistance from Janssen CarePath.
This authorization will last until I am no longer participating in Janssen CarePath, or accessing my Janssen CarePath Account. I understand that I may
cancel or revoke this Authorization at any time by mailing a letter requesting such cancellation to Janssen CarePath, 2250 Perimeter Park Drive, Suite 300,
Morrisville, NC 27560 or by informing my Healthcare Providers and Insurers in writing that I do not want them to share any information with Janssen. I
further understand that cancellation or revocation will not affect Janssen’s ability to use and disclose Protected Health Information that it has received
prior to its receipt of my cancellation and revocation of participation in the program. My authorization will also end if Janssen CarePath support programs
or the Janssen CarePath Account is discontinued. Furthermore, I understand that I have the right to see or copy the Protected Health Information my
Healthcare Providers or Insurers have given to Janssen.
Patient name: Date of birth (mm/dd/yyyy):
Patient address:
City: State: ZIP Code:
Patient sign here: Date:
If the patient cannot sign, patient’s legally authorized representative must sign below:
By: Date:
(Signature of person legally authorized to sign for patient)
Describe relationship to patient and authority to make medical decisions for patient:
Janssen CarePath
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
Fax 866-836-0567
© Janssen Therapeutics, Division of Janssen Products, LP 2020 June 2020 cp-14843v3
