Patient Enrollment Form

SPRAVATO withMe is unable to process any information without the signed Patient Authorization Form, included on the last 2 pages of this form. The Patient Authorization Form is also available upon request by calling 844-4S-WITHME (844-479-4846). The information you provide will be used by Johnson & Johnson Health Care Systems Inc., our affiliates, and our service providers for your patient’s enrollment and participation in SPRAVATO withMe. Our Privacy Policy governs the use of the information you provide. By submitting this form, you indicate that you read, understand, and agree to these terms.

All fields are REQUIRED except where indicated as (*) optional

1. Patient Information

Patient First Name

Patient Last Name

Sex:

Male Female

Date of Birth

Preferred Language:

English Spanish Other

Address

City

State

Zip

Phone

Is it

Cell Home

Best Time to Contact

AM PM

*Email

*Caregiver/Contact

(A caregiver/contact is someone who can be contacted in place of the patient.)

Relationship to Patient

Phone

Is it

Cell Home

Best Time to Contact

AM PM

*Email

‎

I authorize SPRAVATO withMe to leave a message if I am unavailable when they call.

If I cannot be reached, I authorize SPRAVATO withMe to contact my caregiver

I prefer and authorize SPRAVATO withMe to contact my caregiver in place of me.

2. Insurance Information

(Please attach a copy of the front and back of insurance cards OR complete below.)

Primary Medical Insurance

Phone

Employer

Cardholder Name (First, MI, Last)

Policy #

Group #

Secondary Medical Insurance/Behavioral Health Insurance

Phone

Employer

Cardholder Name (First, MI, Last)

Group #

Policy #

Prescription Drug Insurance

Phone

Employer

Cardholder Name (First, MI, Last)

BIN #

Policy #

Group #

3. Prescriber Information

Where do you plan for the patient to be treated?

Prescriber’s Office (CMS-1500)

Outpatient Facility (UB-04)

Undecided

Treating Physician Name (First, Last)

Specialty (optional)

Treatment Site Name

Treatment Site Contact

Address

City

State

Zip

Phone

Fax

After Hours Phone

Email address

Provider NPI #

DEA #

State License #

Tax ID #

I agree that my contact information may be shared with another healthcare professional, when requested, to assist with patient care.

If referring physician is known: Name (First, Last)

Phone

Fax

Please see the full Prescribing Information, including Boxed WARNINGS, and Medication Guide for SPRAVATO®. Provide the Medication Guide to your patients and encourage discussion.

4. Product Acquisition Plan (Optional)

Healthcare Setting or Pharmacy must be Risk Evaluation and Mitigation Strategy (REMS)-certified prior to ordering and/or dispensing SPRAVATO®. Information will be provided based on the patient’s health plan requirements (major medical and/or prescription). Please select one of the following checkboxes for your preferred product acquisition:

‎

REMS-certified Pharmacy: We will provide information associated with REMS-certified pharmacies that are covered under this patient’s plan.

Medical Buy & Bill

5. Clinical Information

(The information requested here is needed to investigate benefits. This form does NOT serve as a valid prescription.)

Common ICD-10 Codes: *These codes do not represent all available codes.

F32.1

F32.2

F32.3

F33.2

R45.851

Other ICD-10 Code

Treatment History

Concomitant Oral Antidepressant

Other therapies prescribed within the current depressive episode

Indication

‎

Treatment-resistant depression in adults: The patient with MDD and in the current depressive episode has not responded adequately to at least two different antidepressants of adequate dose and duration

Depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior

Treatment Location Ship to:

Site Name

Site Contact

Phone

Address

City

State

Zip

Information about your patient’s insurance coverage, cost support options, and treatment support is given by service providers for SPRAVATO withMe. The information you get does not require you or your patient to use any Janssen product. Because the information we give you comes from outside sources, SPRAVATO withMe cannot promise the information will be complete. SPRAVATO withMe cost support is not for patients in the Johnson & Johnson Patient Assistance Foundation.

SPRAVATO withMe is limited to education for patients about SPRAVATO®, its administration, and/or their disease, and is not intended to provide medical advice, replace a treatment plan from the patient’s doctor or nurse, or provide case management services.

Please see the full Prescribing Information, including Boxed WARNINGS, and Medication Guide for SPRAVATO®. Provide the Medication Guide to your patients and encourage discussion.

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