Janssen CarePath
2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560
Fax 855-227-3721
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 855-227-3721, 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 Pharmaceuticals, Inc. 2020 September 2020 cp-54062v5
