Patient Authorization Form

Patients should read the Patient Authorization, check the desired permission boxes, sign, and return both pages of the Form to the Janssen Patient Support Program.

Completed Form may be faxed to 844-577-7282 or mailed to Partner withMe, 680 Century Point, Lake Mary, FL 32746.
Patients may also read, eSign, and submit a digital version of this form at SpravatowithMePatientAuth.com

Patient Name

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

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 pharmacies that dispense and ship my medication and service providers for the patient support programs may be paid by Janssen for their services and data. This may include payment for sharing Protected Health Information and other data in connection with these programs, 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: Partner withMe, 680 Century Point, Lake Mary, FL 32746.

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 :

Patient sign here:

Date

If the patient cannot sign, patient’s legally authorized representative must sign below:

By:

(Signature of person legally authorized to sign for patient)

Print Name:

Date

Describe relationship to patient and authority to make medical decisions for patient:

Your information will be encrypted.