© Johnson & Johnson Patient Assistance Foundation, Inc. page 4 of 5
PATIENT DECLARATION AND PATIENT AUTHORIZATION TO SHARE HEALTH INFORMATION
Please read, sign and date on page 2, Patient Section 4.
The information on this form is correct and complete including all copies of documents proving my income.
The product(s) provided under this patient assistance program will not be sold or traded.
I will notify the Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) Patient Assistance Program ("Program") within
thirty (30) days if there is any change in the status of my eligibility (related to changes in income or health coverage) to receive
products through this program. This includes a change in my eligibility to participate in the Medicare program due to changes in
my age or disability status or my enrollment in Medicare Part D.
Not to attempt to claim or submit any costs associated with the medicine(s) I receive under the Johnson & Johnson Patient Assistance
Foundation, Inc. Patient Assistance Program to any person or entity, including my Medicare Part D plan.
Not to seek true out-of-pocket (TrOOP) credit under the Medicare Part D program for the cost of the medicine(s) I receive under this program.
I authorize the following communications:
Specically, I authorize JJPAF to contact me to request my assistance with analysis related to the quality and efcacy of the JJPAF Program.
When signing this application, I am agreeing to allow the manufacturer or its agent to contact me or my healthcare provider for
additional information, if needed, to evaluate any adverse event or product complaint I or my provider reported on my behalf.
The Program to contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services,
social workers, or patient advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage
or other funds, and disclose to them information contained in my JJPAF Program application or information about my prescribed
medications and medical condition that has been provided by my physician, healthcare provider, or pharmacist.
I understand that JJPAF and the vendors associated with administrating the Program (collectively the “Program
Reserve the right without notice to change the application form, change the Program or Program criteria, or terminate my enrollment
at any time, without notice.
May request and obtain information about my or my family’s income.
Patient Authorization To Share Health Information: By signing on page 2, I hereby authorize:
My doctor(s), pharmacy and other healthcare providers, and my health plan or insurers (“Entities”) to disclose to and share with JJPAF,
the Program Administrators and their afliates, agents, contractors, representatives, service providers, and assignees (“JJPAF Recipients”),
my individually identiable health information, which may include my full name, demographic information, nancial information, and
information related to medical condition, treatment, care management, health insurance and benets, medication history, and prescriptions
(collectively, “Health Information”), whether in written or verbal form, including portions of my medical record.
The JJPAF Recipients to access, obtain, use, disclose, receive, and maintain my Health Information for purposes of processing this Application,
verifying the information provided in this Application, assisting in the identication of or determining eligibility under the Program and other
patient assistance resources, investigating and verifying my insurance benets, coordinating the dispensing and delivery of medication,
and conducting the additional services described above and to run the Program, including internal business purposes.
In addition, by signing on page 2, I understand and agree that:
I may refuse to sign the form on page 2. This authorization is voluntary, but if I refuse to sign this form, I know that this means that I may
no longer be eligible to receive assistance from the Program. I understand that my doctor(s), pharmacy and other healthcare providers,
and my health plan or insurers may not condition the provision of my treatment, or coverage of my benets, on my signing this authorization.
Health Information released under this authorization may no longer be protected by state and federal law, including the Health
Insurance Portability and Accountability Act (HIPAA).
The information provided in this application may be subject to random audits and verication, and that during such audits and
verication processes, I may be asked for additional supporting documentation and will comply with such requests.
I may withdraw my authorization at any time by mailing a written withdrawal to JJPAF at PO Box 0367, Chestereld, MO 63006,
however, such withdrawal will not have an impact on any actions that have already been taken in reliance on this authorization.
This authorization will last until I am no longer participating in the Program or sooner as limited by applicable state law.
I have a right to receive a copy of this authorization.
Patient Assistance Program Application
DO NOT SUBMIT THIS PAGE—IT IS FOR PATIENT AND HEALTHCARE PROFESSIONAL RECORDS ONLY
Revised: August 2020*See full U.S. prescribing information, including Black Box warning.