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: __________________________________________ Address, City, State, ZIP ____________________________________________________________________________________________________ Date of Birth: ________________________________________________ Social Security #: ___________________________________________ Email: ______________________________________________________ FINANCIAL INFORMATION (All Values Should Reflect Yearly Amounts for Entire Household)
Total Gross Yearly Income $ ____________________________________ Household Size: ______________________________________________  Attached is a copy of my most recent federal tax return
(Number of people who contribute to or are dependent on your household  I do not file federal taxes
Your application may be subject to audit or request for additional documentation.
INSURANCE INFORMATION
Do you have any public or private insurance? MEDICARE
Medicare Policy # __________________________________________________________________________________________ Are you enrolled in a Medicare prescription drug plan? Value of Assets $________________________________ (To determine eligibility for Part D Low Income Subsidy [LIS]) (Include: checking & savings accounts, certificates of deposits, stocks & 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.) Insurance Company: _____________________________ Plan Name # ____________________________________________ Telephone: _____________________________________ Policy ID # ______________________________________________ MEDICAID
If “Yes”, are you eligible for prescription drug benefits?  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)
THIS PROGRAM IS LIMITED TO PATIENTS BEING TREATED ON AN OUTPATIENT BASIS

PHARMACY CARD DISTRIBUTION - Patients receiving assistance through the Pharmacy Card will need a valid prescription from their prescribing physician to
access medication.
 AXERT® (almotriptan malate) Tablets
 RAZADYNE® (galantamine HBr) Tablets/Oral Solution  CONCERTA® (methylphenidate HCI) Extended-Release Tablets CII  RAZADYNE® ER (galantamine HBr) Extended-Release  DITROPAN® XL (oxybutynin chloride) Extended Release Tablets  DURAGESIC® (fentanyl transdermal system) CII  ELMIRON® (pentosan polysulfate sodium) Capsules  TOPAMAX® (topiramate) Sprinkle Capsules  LEVAQUIN® (levofloxacin) Tablets/Oral Solution  NUCYNTA® (tapentadol) immediate-release oral tablets C-II  ULTRACET® (tramadol hydrochloride/acetaminophen) Tablets  NUCYNTA® ER (tapentadol extended-release oral tablets)  ULTRAM® (tramadol hydrochloride) Tablets  ULTRAM® ER (tramadol HCL) Extended-Release Tablets  PREZISTA® (darunavir) Oral Suspension  ZYTIGA® (abiraterone acetate) Tablets Please check box to indicate if patient is currently on PREZISTA® 
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.
 DOXIL® (doxorubicin HCL liposome injection)
 PARAFON FORTE® DSC (chlorzoxazone) Caplets  REMICADE® (infliximab) for IV Injection  RISPERDAL® CONSTA® (risperidone) Long-Acting Injection  HALDOL® (haloperidol) Decanoate Injection  SIMPONI® ARIATM (golimumab) for Infusion  INVEGA® SUSTENNA® (paliperidone palmitate) Extended-Release  SPORANOX® (itraconazole) Oral Solution  TERAZOL® 3 (terconazole) Vaginal Cream or Suppositories  NATRECOR ® (nesiritide) for Injection  TERAZOL® 7 (terconazole) Vaginal Cream  ORTHOVISC® High Molecular Weight Hyaluronan DIRECT TO PATIENT DISPENSE – Medications selected for Direct to Patient Dispense will be shipped to the patient’s residence. Patients deemed eligible
for the Program are eligible for up to 12 months of assistance as long as they continue to meet eligibility requirements.
 IMBRUVICATM (ibrutinib) Capsules
PHARMACY CARD OR DIRECT TO PHYSICIAN DISTRIBUTION - Check the preferred method of distribution when selecting products below. See
limitations above.
INVEGA® (paliperidone) Extended-Release Tablets  Pharmacy Card or  Direct to Physician PANCREAZE® (pancrelipase) Delayed-Release Capsules  Pharmacy Card or  Direct to Physician  Pharmacy Card or  Direct to Physician If requesting PROCRIT®, is patient being treated on renal dialysis? YES  NO 
RISPERDAL® (risperidone) Tablets/ Oral Solution  Pharmacy Card or  Direct to Physician RISPERDAL® (risperidone) M-TAB® Orally Disintegrating Tablets  Pharmacy Card or  Direct to Physician STELARA® (ustekinumab) Injection  Pharmacy Card or  Direct to Physician EDURANT® (rilpivirne) Tablets  Pharmacy Card or  Direct to Physician  Pharmacy Card or  Direct to Physician  Pharmacy Card or  Direct to Physician Please check box to indicate if patient is currently on PREZISTA®  INTELENCE®  or EDURANT® 
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:________________________________________ Telephone: ___________________________________________ Facility Name: _________________________________________ Fax:_________________________________________________ Office Contact Name: ____________________________________ Tax ID #: ____________________________________________ Email: ________________________________________________ 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:__________________ Quantity: __________________ Days Supply:_______________ Quantity: _______________ Days Supply:____________ Number of Refills (maximum 12): ___________ Number of Refills (maximum 12): ____________ State License # (required):
Physician DEA # (required):
_________________________________
__________________________
For IMBRUVICA™ patients, please complete this additional section:
Allergies  NKDA or List: __________________________________________________________________________________
Current Therapies/Medications  None or List ________________________________________________________________
_________________________________________________________________________________________________________
NOTICE: For New York State Prescribers, please provide order for IMBRUVICA™ on your NYS official prescription form.
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. This program is limited to patients being
treated on an outpatient basis. 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 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 (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 privacy laws will not • 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 consent • 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: ________________________________________
Patient Authorization To Elect Representative for Purposes of Program Enrollment (if applicable)

I permit the Johnson & Johnson Patient Assistance Foundation (JJPAF) to speak with the following person about my application. This
includes discussing the status of my application, insurance and financial questions, missing documentation, if any, and any other
issues related to my application.
Name of Authorized Representative:___________________________________ Telephone:_________________________________
Organization Name:________________________________________________ Email:_____________________________________
By signing below, you allow this representative to speak on your behalf on any matter regarding your application with JJPAF:
Patient Signature:__________________________________________________ Date:____________________
A copy of this form must be provided to the patient.
Johnson & Johnson Patient Assistance Foundation, Inc. 2009

Source: http://www.jjpaf.org/resources/jjpaf-application.pdf