Janssen CarePath Savings Program
Patient Assignment of Benefits
© Janssen Pharmaceuticals, Inc. 2020 10/20 cp-112479v2
1. OPTIONAL: This form is optional. Signing this form is not required for a patient to receive medical treatment, to start or stay on
therapy, or to be enrolled in Janssen CarePath.
2. AUTHORIZATION: By signing this form, the patient authorizes Janssen CarePath to issue payment directly to their provider
for any reimbursement amounts attributable to the costs of medication administered in their provider’s office. This form’s
authorization is not limited to one provider, but grants patient authorization for all providers the patient is treated by that are
enrolled in Janssen CarePath.
3. BENEFITS: This form is limited to repayment of the costs of medication that are administered in the provider’s office. It does not
cover the cost of the office visit or your treatment’s administration.
4. INSTRUCTIONS: Patient must read this form, complete all fields, sign, and return this form to their provider if the patient is in
agreement with the assignment of the above benefits to all providers from whom the patient receives medical services that are
enrolled in Janssen CarePath. Providers should fax the completed form to Janssen CarePath at 833-777-7282, or mail to Janssen
CarePath, PO Box 13135, La Jolla, CA 92037.
5. CANCELLATION: Patient can, at any time, call Janssen CarePath and elect for the rebate check(s) (payment) to be sent directly
to them.
Date of Birth (mm/dd/yyyy):
Janssen CarePath Savings Program Member #:
(from the front of your Savings Program card)
My signature on this Patient Assignment of Benefits Form confirms that I authorize that each of my Janssen CarePath Savings
Program out-of-pocket payment(s) be sent on my behalf to all provider(s) for payment of my out-of-pocket Janssen medication cost(s).
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.
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:
Please read the full Prescribing Information, including Boxed WARNINGS and Medication Guide
for SPRAVATO
®
, and discuss any questions you have with your doctor.
