Janssen CarePath Savings Program
Patient Assignment of Benefits
© Janssen Biotech, Inc. 2018 8/18 cp-53154v3
Treatment Site Representative Signature:
1. Please note that this completed form is required in order for the provider to receive a payment on behalf of the
patient for medication costs.
When submitting an Explanation of Benefits (EOB), a copy of the Health Insurance Claim Form-CMS 1500 (HICF)
or Uniform Billing Form-CMS 1450 (UB-04) must be included.
2. Effective 8/20/18, only providers with a JanssenCarePathPortal.com account will be able to submit this form.
Visit JanssenCarePathPortal.com to create an account and upload this form online or fax it to 855-820-3224.
3. The patient who has directed that payment should be made to the provider must authorize the assignment of
benefits by signing this form. All fields must be completed.
Patient Information and Authorization
Date of Birth (mm/dd/yyyy):
My signature on this Patient Assignment of Benefits Form confirms that I authorize my Janssen CarePath Savings Program benefits
be sent on my behalf to the provider I have designated on this form for payment of my out-of-pocket Janssen medication cost. I also
understand that I may, at any time, call Janssen CarePath and elect for the rebate check(s) to be sent directly to me or for my rebate
to be loaded onto a debit card (if available).
to be loaded onto a debit card (if available).
If the patient cannot sign, patient’s legally authorized representative must sign below.
(Signature of person legally authorized to sign for patient)
Describe relationship to patient and authority to make medical decisions for patient:
Treatment Provider Information and Authorization
My signature on this Patient Assignment of Benefits Form acknowledges that the patient listed above has requested their benefit from
the Janssen CarePath Savings Program be sent to our Treatment Site for payment of the patient's eligible out-of-pocket Janssen
medication costs. I further understand that patient may elect in the future for a rebate check to be sent directly to the patient or for the
rebate to be loaded onto a debit card (if available). At that point, the patient’s Janssen CarePath Savings Program benefit will no longer
be sent to our Treatment Site.
Please read the full Prescribing Information, including Boxed Warnings, and Medication Guide for SIMPONI ARIA
®
, and
discuss any questions you have with your doctor.
