[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287378-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-287378-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","janssen-patient-support-program-patient-authorization-form","Janssen Patient Support Program Patient Authorization Form","","Janssen Patient Support Program Patient Authorization Form collects patient identity and contact details and grants permission for specified healthcare providers and insurers to share the patient’s Protected Health Information. The authorization allows Janssen and designated recipients to receive, use, and share information to determine eligibility, provide services, coordinate coverage and prescriptions, and support program management and data analysis. The form explains privacy protections, non-mandatory signature, cancellation rights, eSign and submission methods, and the authorization’s 10-year effectiveness period.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/janssen-patient-support-program-patient-authorization-form/287378/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/janssen-patient-support-program-patient-authorization-form/287378.png","ImageObject",442,249,{"name":42,"@type":43},"Jake","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"How do patients submit the Janssen Patient Authorization Form?","Question",{"text":62,"@type":63},"Patients should check the desired permission boxes and return both pages. The form can be printed and signed, then scanned and uploaded via a provider portal, or faxed or mailed to Janssen CarePath.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What Protected Health Information is covered by this authorization?",{"text":67,"@type":63},"It includes information related to the patient’s medical condition, treatment, prescriptions, and health insurance coverage.",{"name":69,"@type":60,"acceptedAnswer":70},"Can the patient cancel or change the authorization after signing?",{"text":71,"@type":63},"Yes. The patient may cancel at any time by notifying Janssen in writing and also informing healthcare providers and insurers. Cancellation does not affect how Janssen used or shared information received before cancellation.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},287378,1789632250,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":22},962084928904,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Janssen Patient Support Program Patient Authorization Form  \nPatients should read the Patient Authorization, check the desired permission boxes, and return both pages of the Form to the Janssen Patient Support Program.  \n􀁸 Download a copy, print, check the desired boxes, and sign. Your healthcare provider may scan the completed Form and upload on Provider Portal, or completed Form may be faxed to 877-370-0142 or mailed to Janssen CarePath, PO Box 15510, Pittsburgh, PA 15244.  \n􀁸 You may be able to eSign a digital Form in your healthcare provider’s office or on the Janssen CarePath [Patient Account at MyJanssenCarePath.com](Patient Account at MyJanssenCarePath.com).  \nPatient Name   Date of Birth ( mm/dd/yyyy)   Patient Address   City   State   ZIP Code   Phone Number   Email Address    \nI 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.  \nMy “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”):  \n􀁸 Johnson & Johnson Health Care Systems Inc. , its affiliated companies, agents, and representatives  \n􀁸 Providers of other sources of funding, including foundations and co-pay assistance providers  \n􀁸 Service providers for the patient support programs, including subcontractors or Healthcare Providers helping Janssen run the programs  \n􀁸 Service providers maintaining , transmitting, de-identifying, aggregating, or analyzing data from Janssen patient support programs  \nAlso, I give permission to Janssen to receive, use, and share my Protected Health Information in order to:  \n􀁸 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  \n􀁸 manage the Janssen patient support programs  \n© Johnson & Johnson Health Care Systems Inc. 2023 11/23 cp-414798v1 Page 1 of 3  \nJanssen Patient Support Program Patient Authorization Form  \n􀁸 give me educational and adherence materials, information, and resources related to my Janssen medication in connection with Janssen patient support programs  \n􀁸 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  \n􀁸 verify, assist with, and coordinate my coverage for my Janssen medication with my Insurers and Healthcare Providers  \n􀁸 coordinate prescription or treatment location and associated scheduling  \n􀁸 conduct analysis to help Janssen evaluate, create, and improve its products, services, and customer support for patients prescribed Janssen medications  \n􀁸 share and give access to information created by the Janssen patient support programs that may be useful for my care  \nI understand that my Protected Health Information may be shared by Janssen for the uses written in this Form to:  \n􀁸 My Insurers  \n􀁸 My Healthcare Providers  \n􀁸 Any of the persons given permission to receive and use my Protected Health Information as mentioned above  \n􀁸 Any individual I give permission as an additional contact  \nJanssen 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.  \nI understand that I am not required to sign this Form. My choice about whether to sign will not change how my Heal","cbCaijW3bRZ6RUo0","https://ap.wps.com/l/cbCaijW3bRZ6RUo0","pdf",128385,"English","# Patient Authorization Instructions\n## Patient Information and Permissions\n## Uses, Recipients, Privacy Notice, and Disclosures\n## Authorization Duration and Cancellation Options","[{\"question\":\"How do patients submit the Janssen Patient Authorization Form?\",\"answer\":\"Patients should check the desired permission boxes and return both pages. The form can be printed and signed, then scanned and uploaded via a provider portal, or faxed or mailed to Janssen CarePath.\"},{\"question\":\"What Protected Health Information is covered by this authorization?\",\"answer\":\"It includes information related to the patient’s medical condition, treatment, prescriptions, and health insurance coverage.\"},{\"question\":\"Can the patient cancel or change the authorization after signing?\",\"answer\":\"Yes. The patient may cancel at any time by notifying Janssen in writing and also informing healthcare providers and insurers. Cancellation does not affect how Janssen used or shared information received before cancellation.\"}]","Janssen Patient Support Program Patient Authorization Form | PDF"]