Fillable Janssen CarePath Savings Program Patient Assignment of Benefits (Janssen CarePath)

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Janssen CarePath Savings Program Patient Assignment of Benefits (Janssen CarePath)

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The Janssen CarePath Savings Program Patient Assignment of Benefits (Janssen CarePath) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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Janssen CarePath Savings Program
Patient Assignment of Benefits
© Johnson & Johnson Health Care Systems Inc. 2019 8/19 cp-16452v2
1. Please note that this completed form is required in order for the patient’s rebate check to be sent to the provider
on the patient’s behalf for the patient’s medication costs.
2. Patients must read the Patient Assignment of Benefits and download, print, and sign.
3. Completed form may be uploaded to Provider Portal (JanssenCarePathPortal.com)
Provider Information
Site Name:
Provider First Name:
Provider Last Name:
Address:
City:
State:
ZIP Code:
Site Phone:
Site Fax:
Patient Information
Patient:
name:
Date of Birth (mm/dd/yyyy):
Patient address:
City:
State:
ZIP Code:
Patient Authorization
My signature on this Patient Assignment of Benefits Form confirms that I authorize each of my Janssen CarePath Savings Program
rebate check(s) 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).
Patient Signature:
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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Janssen CarePath Savings Program Patient Assignment of Benefits (Janssen CarePath)

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Completed 22 July 2021

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