Fillable Janssen Patient Support Program Patient Authorization Form (Janssen CarePath)

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Janssen Patient Support Program Patient Authorization Form (Janssen CarePath)

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The Janssen Patient Support Program Patient Authorization Form (Janssen CarePath) form is 2 pages long and contains:

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  • 3 check-boxes
  • 21 other fields

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File type: PDF

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2© Janssen Pharmaceuticals, Inc. 2021 6/21 cp-204162v2
Janssen Patient Support Program
Patient Authorization Form
Patients should read the Patient Authorization, check the desired permission boxes and return
both pages of the form to Janssen Patient Support Program
• Download a copy, print, check the desired boxes and sign. Completed form may be faxed to
833-200-6306 or mailed to Janssen CarePath, PO Box 13135, La Jolla, CA 92037
Patient Name: Date of Birth: (mm/dd/yyyy)
Patient Address:
City: State: ZIP Code:
Phone Number: Email Address:
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 as described on this Form.
My “Protected Health Information” includes any and all 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, including foundations and co-pay assistance providers
• Service providers for the patient support programs, including subcontractors or healthcare
providers helping Janssen run the programs
• Service providers maintaining, transmitting, de-identifying, aggregating, or analyzing data from
Janssen patient support programs
Also, 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, contact me about, and provide services relating to Janssen patient
support programs, including in-home services
• 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 tell my Healthcare Provider that I am participating in 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
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2© Janssen Pharmaceuticals, Inc. 2021 6/21 cp-204162v2
Janssen and the other data recipients listed on this Form may share information about me as permitted
on this Form or if any information that specifically identifies me is removed. I understand that Janssen
will use reasonable efforts to keep my information private but once my Protected Health Information is
disclosed as allowed on this Form, it 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. I understand that my Healthcare Providers may be paid by Janssen for
sharing my Protected Health Information with Janssen as allowed on this Form.
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 name (print):
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 Patient Support Program
Patient Authorization Form
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Janssen Patient Support Program Patient Authorization Form (Janssen CarePath)

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Completed 22 July 2021

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