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 Prescriber Name (First, Last): Said A. Ibrahimi, MD

Treatment Site Name: Vortex Psychiatry

Treatment Site Contact: Bria or Veronica

Address: 4155 Blackhawk Plaza Circle, Suite 240, City: Danville, State: CA, ZIP: 94506

Phone: 925-648-2650, Fax: 925-478-7755, Email: vortexpsychiatry@outlook.com

Prescriber NPI #: 1740560861, Prescriber Tax ID #: 47-1687401

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. Clinical Information

(This form does NOT serve as a valid prescription. The information requested here is needed to investigate benefits. Benefits will be investigated for both 84 mg and 56 mg dose strengths.)

Common ICD-10 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

5. Prior Authorization Form Assistance and Status Monitoring

Janssen automatically provides Prior Authorization form assistance, including status updates where required by a patient's health plan, when you enroll your patient into SPRAVATO withMe.

Check here ONLY if you DO NOT want SPRAVATO withMe to provide Prior Authorization form assistance for your patient.

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.

Janssen Patient Support Program

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.