To apply for assistance, complete this application, attach your most recent

PATIENT ASSISTANCE PROGRAM APPLICATION
To Be Completed By Patient
To apply for assistance, please mail or fax the following items:
•
Mail to: Patient Assistance Program
Complete Patient Page
PO Box 221857
Complete Products to be Distributed Page
Charlotte, NC 28222-1857
Complete Physician Page
Telephone: 800-652-6227
Signed Patient Declaration and Authorization Page
Fax: 888-526-5168
Copy of Patient’s most recent federal tax return
PATIENT INFORMATION
Name: ______________________________________________________ Primary Telephone: __________________________________________ Social Security #: ____________________________________________ Address, City, State, ZIP _____________________________________________________________________________________________________ Gender F Male F Female FINANCIAL INFORMATION (All Values Should Reflect Yearly Amounts for Entire Household)
Total Gross Yearly Income $ ____________________________________ Value of Assets $ _________________________________________ Household Size: ______________________________________________ (Include: checking & savings accounts, certificates of deposit, stocks & (Number of people who contribute to or are dependent on your household bonds, mutual funds, IRAs, cash, and the value of life insurance policies if you turned in your policies for cash right now. Do not include:
homes, vehicles, burial plots or personal possessions.)
Check the applicable box:
F Attached is a copy of my most recent federal tax return
F I do not file federal taxes
INSURANCE INFORMATION
Do you have any public or private insurance? MEDICARE
Medicare Policy # __________________________________________________________________________________________ Are you enrolled in a Medicare prescription drug plan? Plan Name # _____________________________________________ Telephone: _____________________________________ Policy ID # ______________________________________________ MEDICAID
If “Yes”, are you eligible for prescription drug benefits? F Yes - Medicare Savings Program-Only (e.g., QMB, SLMB, QI-1) OTHER STATE/ Are you eligible for other state/government programs
GOVERNMENT that provide prescription drug benefits
(e.g., ADAP, SPAP – State Patient Assistant Program)? PRIVATE/HMO Insurance Company: _____________________________ Telephone: _______________________________________________
Policy ID # ____________ Group ID # ____________ Subscriber Name: _________________________________________ Johnson & Johnson Patient Assistance Foundation, Inc.2009 PATIENT ASSISTANCE PROGRAM APPLICATION
To Be Completed By Physician
Patient Name: ________________________________
PRODUCTS TO BE DISTRIBUTED (Check all applicable)
PHARMACY CARD DISTRIBUTION - Patients receiving assistance through the Pharmacy Card will need a valid prescription from their prescribing
physician to access medication.
F AXERT® Tablets (almotriptan malate)
F CONCERTA® (methylphenidate HCI) Extended-Release Tablets CII F DITROPAN® XL (oxybutynin chloride) Extended Release Tablets F TOPAMAX® (topiramate) Sprinkle Capsules F DURAGESIC® (fentanyl transdermal system) CII F ELMIRON® (pentosan polysulfate sodium) Capsules F ULTRACET® (tramadol hydrochloride/acetaminophen) F FLEXERIL® (cyclobenzaprine HC) Tablets F LEVAQUIN® (levofloxacin) Tablets/Oral Solution F ULTRAM® (tramadol hydrochloride) Tablets F NUCYNTA™ (tapentadol) immidiate-release oral tablets C-II F ULTRAM® ER (tramadol HCL) Extended-Release F RAZADYNE® (galantamine HBr) Tablets/Oral Solution F RAZADYNE® ER (galantamine HBr) Extended-Release Capsules DIRECT TO PHYSICIAN DISTRIBUTION – Medications selected for Direct to Physician Distribution will be shipped to the physician’s office.
Patients deemed eligible for the Program are eligible for up to 12 months of assistance as long as they continue to meet eligibility requirements.
F PARAFON FORTE® DSC (chlorzoxazone) Caplets F DOXIL® (doxorubicin HCL liposome injection) F REMICADE® (infliximab) for IV Injection F RETIN-A® (tretinoin) Cream, Gel or Micro F ERTACZO™ (sertaconazole nitrate) Cream 2% F RISPERDAL® CONSTA® (risperidone) Long-Acting F GRIFULVIN V® (griseofulvin tablets) microsize Tablets F RISPERDAL® CONSTA® (risperidone) Long-Acting F HALDOL® (haloperidol) Decanoate Injection Injection with three week oral Risperdal® therapy F INVEGA® SUSTENNA™ (paliperidone palmitate) Extended- F SPORANOX® (itraconazole) Oral Solution F TERAZOL® 3 (terconazole) Vaginal Cream or F NATRECOR ® (nesiritide) for Injection F ORTHOVISC® High Molecular Weight Hyaluronan F TERAZOL® 7 (terconazole) Vaginal Cream F UVADEX® (Methoxsalen) STERILE SOLUTION PHARMACY CARD OR DIRECT TO PHYSICIAN DISTRIBUTION - Check the preferred method of distribution when selecting products below.
See limitations above.
RISPERDAL® (risperidone) Tablets/ Oral Solution F Pharmacy Card or F Direct to Physician RISPERDAL® (risperidone) M-TAB® Orally Disintegrating Tablets F Pharmacy Card or F Direct to Physician INVEGA® (paliperidone) Extended-Release Tablets F Pharmacy Card or F Direct to Physician F Pharmacy Card or F Direct to Physician F Pharmacy Card or F Direct to Physician F Pharmacy Card or F Direct to Physician
Please check box to indicate if patient is currently on PREZISTA® F or INTELENCE™ F
Johnson & Johnson Patient Assistance Foundation, Inc.2009 PATIENT ASSISTANCE PROGRAM APPLICATION
To Be Completed By Physician
ICD-9 Code (Required for Physician Administered Products Only)
Patient Name: _____________________________ ______________________ ; _____________________
PHYSICIAN INFORMATION
Physician Name:________________________________________ Facility Name: _________________________________________ Tax ID #: ____________________________________________ Office Contact Name: ___________________________________ National Provider ID #: _________________________________ Address City, State, ZIP: _________________________________________________________________________________________ DIRECT TO PHYSICIAN DELIVERY ADDRESS
If the shipping address is different from the physician's address, provide the shipping address below. Facility Name: ___________________________________________ Facility Contact Name: ____________________________________ Business Hours: _______________________________________ Address, City, State, ZIP: __________________________________________________________________________________________ PRESCRIBING INFORMATION (Attach additional prescription if more than two products are selected for Direct to
Physician Distribution)
Patient Name: __________________________________________ Product #1 Name ________________________________ Product #2 Name ________________________________ Dosage: __________________Sig:__________________ Dosage: _______________Sig: ______________________ Number of Refills (maximum 12): ___________ Number of Refills (maximum 12): ____________ State License # (required):
Physician DEA # (required):
_________________________________
__________________________
If this patient is not currently on an oral antipsychotic medication and requires three weeks of oral RISPERDAL®, please attach prescribing
information for both oral RISPERDAL® and RISPERDAL® CONSTA®. The prescription information section above may be completed for
RISPERDAL® CONSTA® therapy extending beyond three weeks.
Johnson & Johnson Patient Assistance Foundation (JJPAF) policy prohibits physicians from charging the patient any fee for enrollment or other activities associated solely with the patient’s participation in this patient assistance program (Program). JJPAF requests that physicians not charge the patient for those professional services associated with this regimen not covered by the patient’s health insurer. No claim may be made to any third party payer (e.g., Medicaid, Medicare, private insurance, etc.) for payment for product provided under the Program. The product(s) provided under this patient assistance program may not be sold or traded and may not be returned for credit. Please indicate your agreement to the terms of Program participation by signing below. In addition, your signature is intended to confirm to JJPAF that: (1) there is a valid medical need for this patient’s prescription; (2) that to the best of your knowledge this patient does not have prescription drug insurance coverage (including Medicare, Medicaid, county funded, or other public programs) for the product(s) listed above; and (3) you are not prohibited from participating in Federally-funded health care programs nor are you on the List of Excluded Individuals/Entities maintained by the HHS Office of Inspector General. Physician Signature:
Johnson & Johnson Patient Assistance Foundation, Inc. 2009 PATIENT ASSISTANCE PROGRAM APPLICATION
To Be Completed By Patient
Patient Declaration

I promise:
• The information on this form is correct and complete including all copies of documents proving my • I will notify the Johnson & Johnson Patient Assistance Foundation (JJPAF) Patient Assistance 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. Patient Authorization To Share Health Information

I allow my doctor(s), any health care providers, and my health plan or insurers to give medical information
relating to my use or need for products provided under the Johnson & Johnson Patient Assistance Foundation
(JJPAF) Patient Assistance program.
I understand:
• This information can include spoken or written facts about my health and payment benefits • It can include copies of my health records • People who work for JJPAF or the Program administrator may see my information but they may use it only to help me get assistance with the costs of my drugs and to run the Program • Every effort will be made to keep my information private but if it is accidentally given out, federal • JJPAF and the Program Administrators reserve the right without notice to change the application form, change the program or program criteria or stop assistance provided by the program at any time • JJPAF may request and obtain information about my or my family’s income • I can withdraw this consent at any time but it will not change any actions taken before I withdrew • I have a right to see or copy information given to JJPAF or Program Administrators • This Authorization will last until I am no longer participating in the Program I KNOW THAT I MAY REFUSE TO SIGN THIS FORM. My choice about whether to sign this form will not change the way health care providers or insurers treat me. If I refuse to sign this form, I know that this means I may no longer be able to receive assistance from the Program. Patient Name (Print) _______________________________ Date ________________ Patient Signature ___________________________________ If the patient cannot sign, patient’s personal representative must sign below Patient Representative Signature ________________________________________ Describe relationship to patient and authority to make medical decisions for patient: A copy of this form must be provided to the patient. Johnson & Johnson Patient Assistance Foundation, Inc.2009

Source: http://www.homemarketingclub.com/PLR/PDF/jjpaf-application.pdf