Fillable Form 2.21: Patient Enrollment Form Cover Sheet (Janssen CarePath)

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Form 2.21: Patient Enrollment Form Cover Sheet (Janssen CarePath)

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The Form 2.21: Patient Enrollment Form Cover Sheet (Janssen CarePath) form is 6 pages long and contains:

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  • 15 check-boxes
  • 100 other fields

Country of origin: US
File type: PDF

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FAX: 833-777-7282 Questions? Call us: 877-CarePath (877-227-3728), Monday–Friday, 8:00 am–8:00 pm ET
UPDATE
2.21
Patient Enrollment Form Cover Sheet
Date Pages
Subject: Janssen CarePath Patient Enrollment
From
Fax #
Help empower your patient to start and stay on your prescribed treatment plan.
To enroll your patient:
1. Complete the required pages of the Patient Enrollment Form as noted below:
Page 1 of 5—REQUIRED: Healthcare Professional Information and Prescription
Please ensure there is a Healthcare Professional signature in the Prescription section.
Page 3 of 5—REQUIRED: Patient Insurance Information and Program Offerings
Pages 4 and 5 of 5—REQUIRED: Janssen Patient Support Program Patient Authorization
Please ensure there is a Patient Signature on the Patient Authorization or that a legally authorized representative has signed
on behalf of the patient.
2. Fax pages 1, 3, 4, and 5 of 5 to Janssen CarePath: 833-777-7282
Upon receipt of your completed Patient Enrollment Form:
• A Fax Confirmation will be sent to your office
• We will begin working on your selected Program Offerings
• We will contact you with next steps
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Please see full Prescribing Information, including Boxed WARNING, for INVEGA SUSTENNA®, INVEGA TRINZA®, and RISPERDAL CONSTA®.
Fax
833-777-7282
Visit us online
JanssenCarePath.com/HCP
Need
help?
Call 877-CarePath (877-227-3728)
Monday–Friday, 8:00 am–8:00 pm ET
Multilingual phone support available
Page 1 of 5
FAX: 833-777-7282 Questions? Call us: 877-CarePath (877-227-3728), Monday–Friday, 8:00 am–8:00 pm ET
Patient Enrollment Form
UPDATE
2.21
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Please see full Prescribing Information, including Boxed WARNING,
for INVEGA SUSTENNA®, INVEGA TRINZA®, and RISPERDAL CONSTA®.
Reset Print Page
Prescription
CHECK HERE IF A COPY OF THE PRESCRIPTION IS ATTACHED AND SIGN BELOW.
INVEGA SUSTENNA® (paliperidone palmitate)
39 mg, 78 mg, 117 mg, 156 mg, 234 mg
Day 1 Dose mg IM Injection Date
Day 8 Dose mg IM Injection Date
(+/–4 days of scheduled dose)
Maintenance Dose mg IM every 4 weeks
Next Injection Date
(See Prescribing Information for missed-dose recommendations)
# Refills Directions
INVEGA TRINZA® (paliperidone palmitate)
273 mg, 410 mg, 546 mg, 819 mg
Dose mg IM every 3 months
Next Injection Date
(See Prescribing Information for missed-dose recommendations)
# Refills Directions
RISPERDAL CONSTA® (risperidone) 12.5 mg, 25 mg, 37.5 mg, 50 mg
Dose mg IM every 2 weeks
QTY Next Injection Date
# Refills Directions
I certify that the above medication is medically necessary and that the information
provided is accurate to the best of my knowledge. By my signature, I also
acknowledge that I have obtained the patient’s authorization to release the above
information and such other information as may be required by Janssen CarePath
to provide the offerings selected. I appoint Janssen CarePath, on my behalf, to
convey this prescription to the dispensing pharmacy of the patient’s choice. I
further certify that (a) any offering provided through Janssen CarePath on behalf
of any patient is not made in exchange for any express or implied agreement or
understanding that I would recommend, prescribe, or use Janssen CarePath or
any other product or service for anyone, and that (b) my decision to prescribe
the products set forth on this page and request Janssen CarePath offerings for my
patient was based solely on my determination of medical necessity as set forth
herein, and that (c) I will not seek reimbursement for any offering provided by or
through Janssen CarePath from any government program or third-party insurer.
X
Dispense as written Date
X
Substitution accepted Date
X
Supervising Physician Signature (if applicable) Date
Supervising Physician Name (print name)
THIS PRESCRIPTION IS ONLY VALID IF RECEIVED BY FAX,
MEETING STATE REGULATIONS
The information you provide will be used by Janssen Pharmaceuticals Inc.,
our affiliates, and our service providers for your enrollment and participation in
Janssen CarePa
th. You may withdraw by calling 877-CarePath (877-227-3728). Our
Privacy Policy further governs the use of the information you provide. By providing
the information and submitting this form, you indicate that you read, understand,
and agree to these terms.
Healthcare Professional (HCP)
HCP Name
Site Name
Address
City State ZIP
Email
Phone
Fax
NPI # State License #
Site Contact(s)*
Site Contact Phone
Site Type: Inpatient/Hospital Outpatient Clinic/Private Practice
Correctional Telepsychiatry
*By including a facility contact name other than the HCP, the HCP is authorizing the facility contact
to accurately relay HCP directions to Janssen CarePath. The HCP will provide appropriate oversight
to ensure orders are accurately relayed and that the HCP is informed about all program information
relevant to the clinical care of the patient.
Prescription
CHECK HERE IF A COPY OF THE PRESCRIPTION IS ATTACHED AND SIGN BELOW.
Patient Name
DOB
(MM/DD/YYYY)
Sex M F
Phone
Address
City State ZIP
Preferred Language: English Spanish Other
Is patient new to this medication? Yes No
Diagnosis/ICD Code
Please list any known drug allergies
Page 2 of 5
Patient insurance benefits investigation and other Janssen CarePath program offerings are provided by third-party service
providers for Janssen CarePath, under contract with Janssen Pharmaceuticals, Inc. (Janssen). Janssen CarePath is not available
to patients participating in the Patient Assistance Program offered by Johnson & Johnson Patient Assistance Foundation. The
availability of information and assistance may vary based on the Janssen medication, geography and other program differences.
Janssen CarePath assists healthcare providers (HCPs) in the determination of whether treatment could be covered by the
applicable third-party payer based on coverage guidelines provided by the payer, and patient information provided by the HCP
under appropriate authorization following the provider’s exclusive determination of medical necessity. This information and
assistance are made available as a convenience to patients, and there is no requirement that patients or HCPs use any Janssen
product in exchange for this information or assistance. Janssen assumes no responsibility for and does not guarantee the quality,
scope, or availability of the information and assistance provided. The third-party service providers, not Janssen, are responsible
for the information and assistance provided under this program. Each HCP and patient is responsible for verifying or confirming
any information provided. All claims and other submissions to payers should be in compliance with all applicable requirements.
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Page 3 of 5
FAX: 833-777-7282 Questions? Call us: 877-CarePath (877-227-3728), Monday–Friday, 8:00 am–8:00 pm ET
Patient Enrollment Form
UPDATE
2.21
Insurance
CHECK HERE IF YOU ARE ATTACHING A COPY OF THE INSURANCE CARDS.
Primary Insurance Name
Phone
Cardholder Name
Policy # Group #
If patient has a separate prescription coverage plan, please list below.
Prescription Plan Name
Phone
Policy # Group #
BIN # PCN #
Alternate Patient Contact (optional)
This contact information will be used to coordinate care if the patient
cannot be reached or is unable to manage his/her care. See full Janssen
Support Program Patient Authorization on pages 4 and 5 of this Patient
Enrollment Form for a full description of what may be discussed with the
alternate patient contact listed below.
Name
Relationship to Patient
Phone
Prior Authorization
CHECK THE BOX BELOW IF YOU WOULD LIKE TO OPT OUT OF PRIOR
AUTHORIZATION FORM ASSISTANCE AND STATUS MONITORING.
Prior Authorization Form Assistance and Status Monitoring
Janssen CarePath assists your office in providing the requirements of the
patient’s health plan related to prior authorization for treatment with their
Janssen medication. Assistance includes obtaining the health plan-specific
prior authorization form and providing it to your office for completion
and submission in the office’s sole discretion. Janssen CarePath also actively
monitors the status of prior authorization submission to the patient’s plan
and provides status updates to your office with respect to the patient’s
prior authorization for treatment with their Janssen medication.
I do NOT wish to receive Prior Authorization Form Assistance or
Status Monitoring.
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Reset Print Page
Please see full Prescribing Information, including Boxed WARNING, for INVEGA SUSTENNA®, INVEGA TRINZA®, and RISPERDAL CONSTA®.
Janssen CarePath Savings Program (Optional)
Eligible patients using commercial insurance can save on out-of-pocket
Janssen medication costs. See program requirements at
JanssenCarePath.com.
I would like Janssen CarePath to check the patient’s eligibility for and
enroll the patient into the Janssen CarePath Savings Program if the results
of this benefits investigation determine that the patient has commercial
or private health insurance.
Program Offerings
CHECK THE BOX NEXT TO EACH OFFERING YOU WOULD LIKE FOR YOUR PATIENT.
Alternate Site of Care Options for Injection
(if available in your geography)
Janssen CarePath will help identify an appropriate alternate site of care
and schedule the patient’s injection appointment at that site. By selecting
one of the injection coordination options below, I understand that Prior
Authorization Form Assistance and Status Monitoring will also be provided,
if applicable.
Fax me a list of available locations.
Contact my patient to select a location.
If my patient does not select a location within 48 hours of being contacted by
Janssen CarePath, I am ordering that the location closest to my patient be selected.
Select a location closest to my patient.
Use the following approved alternate site of care:
By naming the above location, I attest that I do not have a financial relationship
with the alternate site of care listed. A list of approved alternate sites of care
can be found at JanssenConnectLocator.com.
Reminder Alerts Only
Please provide reminder alerts for my patient who will be receiving
injections in my office, per my patient’s request.
My patient is interested in receiving text alerts in addition to receiving
phone calls.* Note: This opt-in must align with the patient’s selection
for text alerts on page 5.
Preferred number t
o use for my patient’s reminders
My patient’s next injection at my office is scheduled for:
*Please provide mobile number above. Standard text message rates apply.
Janssen CarePath Savings Program (Optional)
Page 4 of 5
Janssen Patient Support Program
Patient Authorization Form
• Patients should read the Patient Authorization, check the desired permission boxes, sign, and
return the form to Janssen Patient Support Program
• •
Your healthcare provider may scan the completed form and upload on Provider Portal, or
completed form may be faxed to 833-777-7282 or mailed to Janssen CarePath, PO Box 13135,
La Jolla, CA 92037
• •
You may be able to eSign a digital form in your healthcare provider’s office
Patient Name Email
I give permission for each of my “Healthcare Providers” (eg, my physicians, pharmacists, specialty
pharmacies, other healthcare providers, and their staff) and “Insurers” (eg, my health insurance plans)
to share my Protected Health Information.
My “Protected Health Information” includes but is not limited to the following information related to
my medical condition, treatment, prescriptions, and health insurance coverage.
The following person(s) or class of person(s) are given permission to receive and use my Protected
Health Information (collectively “Janssen”):
• Johnson & Johnson Health Care Systems Inc., its affiliated companies, agents, and representatives
• Providers of other sources of funding include foundations and co-pay assistance providers
• Service providers supporting or analyzing data from Janssen patient support programs
Specifically, I give permission to Janssen to receive, use, and share my Protected Health Information in
order to:
• see if I qualify for, sign me up for, and contact me about Janssen patient support programs
• manage the Janssen patient support programs
• give me educational and adherence materials, information, and resources related to my Janssen
medication in connection with Janssen patient support programs
• communicate with my Healthcare Providers regarding access to, reimbursement for, and fulfillment
of my Janssen medication, and to confirm to my Healthcare Provider that support has been
provided by the Janssen patient support programs
• verify, assist with, and coordinate my coverage for my Janssen medication with my Insurers and
Healthcare Providers
• coordinate prescription or treatment location and associated scheduling
• conduct analysis to help Janssen evaluate, create, and improve its products, services, and customer
support for patients prescribed Janssen medications
• share and give access to information created by the Janssen patient support programs that may be
useful for my care
I understand that my Protected Health Information may be shared by Janssen for the uses written in
this Form to:
• My Insurers
• My Healthcare Providers
• Any of the persons given permission to receive and use my Protected Health Information as
mentioned above
• Any individual I give permission as an additional contact
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Page 5 of 5
Janssen Patient Support Program
Patient Authorization Form
© Janssen Pharmaceuticals, Inc. 2021 February 2021 cp-51040v6
Janssen Patient Support Program
Patient Authorization Form
I understand that my Protected Health Information will not be used or shared by Janssen for any other
use without my permission. Janssen may share information about me where legally allowed or if any
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 share 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 Form. My choice about whether to sign will not change
how my Healthcare Providers or Insurers treat me. If I do not sign this Form, or cancel or remove my
permission later, I understand I will not be able to participate or receive assistance from Janssen’s
patient support programs.
This Form will remain in effect 10 years from the date of signature, except where state law requires
a shorter time, or until I am no longer participating in any Janssen patient support programs.
Information collected before that date may continue to be used for the purposes set forth in this Form.
I understand that I may cancel the permissions given by this Form at any time by letting Janssen know
in writing at: Janssen CarePath, PO Box 13135, La Jolla, CA 92037.
I can also cancel my permission by letting my Healthcare Providers and Insurers know in writing that I
do not want them to share any information with Janssen.
I further understand that if I cancel my permission it will not affect how Janssen uses and shares my
Protected Health Information received by Janssen prior to my cancellation.
I understand I may request a copy of this Form.
Permission for communications outside of Janssen patient support programs:
Yes, I would like to receive communications relating to my Janssen medication.
Yes, I would like to receive communications relating to other Janssen products and services.
For privacy rights and choices specific to California residents, please see Janssen’s California privacy
notice available at https://www.janssen.com/us/privacy-policy#california
Permission for text communications:
Yes, I would like to receive text messages. By selecting this option, I agree to receive text messages
as allowed by this form to the cell phone number provided below. Message and data rates may
apply. Message frequency varies. I understand I am not required to provide my permission to
receive text messages to participate in the Janssen patient support programs or to receive any other
communications I have selected.
Cell phone number:
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:
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Form 2.21: Patient Enrollment Form Cover Sheet (Janssen CarePath)

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Completed 22 July 2021

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