For assistance or additional information, call 877-CarePath (877-227-3728), Monday–Friday, 8:00 am–8:00 pm ET
PATIENT INFORMATION (*Required)
*NAME *GENDER Male Female *DATE OF BIRTH (MM/DD/YYYY)
*ADDRESS *CITY *STATE *ZIP CODE
*PRIMARY PHONE
(Best number to call 8:00 a m –8:00 pm ET, weekdays) E-MAIL
*If you’re unavailable when we call, is it ok for us to leave a message including the name of your medication? Yes No
1. Do you currently have commercial or private health insurance
that you will use for your Janssen treatment, including
commercial insurance provided through an employer or former
employer, provided to you as a federal or state employee, and
insurance you pay for yourself, as well as plans available through
state and federal healthcare exchanges?
Yes, I have commercial or private health insurance that I
will use for my Janssen treatment
No, I do not have commercial or private health insurance
that I will use for my Janssen treatment
2. Do you confirm that you will NOT seek reimbursement from
any state or federal government-funded healthcare program
to cover a portion of the Janssen treatment costs such as
Medicare Parts A, B, C (also known as Medicare Advantage
Plan), D, and Medicare Supplement, Medicaid, TRICARE,
Department of Defense, or Veterans Administration?
Yes, I confirm that I will NOT seek reimbursement from
any state or federal government-funded program for my
Janssen treatment
No, I may seek reimbursement from a state or federal
government-funded healthcare program for my
Janssen treatment
3. Do you confirm that you will not submit out-of-pocket costs paid
by this program as a claim for payment to any third-party payer,
pharmaceutical patient assistance foundation, or account such
as a Flexible Spending Account (FSA), a Health Savings Account
(HSA), or a Health Reimbursement Account (HRA)?
Yes, I confirm that I will NOT submit out-of-pocket costs paid
by this program as a claim for payment to any third-party
payer, pharmaceutical patient assistance foundation,
or account
No, I may submit out-of-pocket costs paid by this program
as a claim for payment to a third-party payer, pharmaceutical
patient assistance foundation, or account
Treatment Administration Rebate Program
Patient Enrollment Form
*Required
*SELECT ONE: Enrollment Update Information Only
Please read the full Prescribing Information, including Boxed Warnings, and Medication Guide for SIMPONI ARIA®,
and discuss any questions you have with your doctor.
© Janssen Biotech, Inc. 2020 9/20 cp-71919v2
Phone: 877-CarePath (877-227-3728) Fax: 844-678-TARP (844-678-8277) MyJanssenCarePath.com
Mail or fax completed enrollment form to: Mail: Janssen CarePath Treatment Administration Rebate Program, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560 Fax: 844-678-TARP (844-678-8277)
My signature below certifies that I have completed all of the above sections completely, accurately, and
to the best of my knowledge, and that I have read, understand, and agree to the Patient Authorization to
release my Protected Health Information as indicated on the next page of this form, including but not
limited to spoken or written facts about my health and payment benefits that I may have. It can include
copies of records from my healthcare providers or health plans about my health or health care. I understand,
accept, and comply with all requirements and restrictions described in the eligibility requirements provided
on the next page and I understand that redeeming this benefit is consistent with the requirements of my
health plan.
PATIENT SIGNATURE
DATE PATIENT NAME
If the patient cannot sign, patient’s personal representative must sign below (Please print)
PATIENT NAME BY
(Signature of person signing for patient)
RELATIONSHIP TO PATIENT AND AUTHORITY TO MAKE MEDICAL DECISIONS FOR PATIENT
NOTE: PLEASE READ THE PATIENT ELIGIBILITY REQUIREMENTS ON THE NEXT PAGE PRIOR TO COMPLETING THIS FORM.
By submitting this form, I am requesting to be enrolled in Janssen CarePath Treatment Administration
Rebate Program for SIMPONI ARIA
®
(the “Program”). I understand that my personal information
will be used by Janssen Biotech, Inc., the maker of SIMPONI ARIA
®
, including our affiliates and
our service providers that work on their behalf (the “Companies”), in connection with the Program,
to help me get assistance with the treatment administration costs for SIMPONI ARIA
®
, or as
otherwise required or allowed under the law. I also understand that the Companies may use my
name and contact information for market and outcomes research and to improve the information
that the Companies provide to patients who are being treated with SIMPONI ARIA
®
.
I understand that the Companies may de-identify my information and use or disclose the
de-identified information for any purpose permitted by law. I understand that they will take
commercially reasonable efforts to keep my information private. I understand that the Companies
may contact me by telephone, postal mail, or e-mail (if I provide an e-mail), in connection with
my enrollment in the Program. I understand and agree that by enrolling in the Program I may also
enroll to receive the information and resources provided by Janssen CarePath, a support program
for SIMPONI ARIA
®
and other Janssen Biotech, Inc., products. If I choose to participate, the
information and resources may include providing educational materials related to my treatment.
I understand that I am responsible for submitting a rebate request including an Explanation of
Benefits (EOB) and proof of provider payment for my out-of-pocket treatment administration
costs to receive payment under the Treatment Administration Rebate Program. The Program will
use the information I submit to determine the amount of treatment administration costs for
SIMPONI ARIA
®
that Janssen Biotech, Inc., will reimburse. That amount will be issued via check
payable to me. I further understand that if I do not submit an EOB and proof of provider payment,
the Program cannot process my rebate request.
I understand that I can cancel participation in the Program at any time by notifying
Janssen CarePath at 877-CarePath (877-227-3728). Our Privacy Policy governs the use of
the information you provide.
Monday–Friday, 8:00 am–8:00 pm ET
3 ways for patient to enroll: Review the program requirements on the next page, then choose the enrollment option you prefer:
Mail or Fax
Complete and sign this form above and mail or fax to:
Mail: Janssen CarePath Treatment Administration Rebate Program
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
OR
Fax: 844-678-TARP (844-678-8277)
Online at MyJanssenCarePath.com
To access the enrollment site, you will need to
create an account if you don’t already have one.
Phone
877-CarePath (877-227-3728)
Monday–Friday, 8:00
am
–8:00
pm
ET
