eHIPAA

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Phone:
866-228-3546

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Why should I sign this Form?
This Form gives your Healthcare Providers permission to use and share your medical information with the patient support programs offered by Johnson & Johnson.

What health information am I sharing and with whom?
I give permission for my Healthcare Providers and Insurers (eg, my health insurance plans) to share my Protected Health Information, as described on this Form.

My Protected Health Information includes information related to: my medical condition, treatment, prescriptions, and health insurance coverage

My Healthcare Providers may include: physicians, pharmacists, specialty pharmacies, other healthcare providers, and staff members at my healthcare providers’ offices

I give permission to these people or groups to receive and use my Protected Health Information (collectively “J&J”):

My Protected Health Information may be shared by J&J with these people and groups: my Insurers, my Healthcare Providers, any other people given permission to receive and use my Protected Health Information (as mentioned above), anyone I give permission to as an additional contact, and service providers who review data from J&J’s patient support programs

J&J and the other groups on this Form may share information about me in 2 ways: as permitted on this Form, and if any information that identifies me is removed from what has been shared

How can giving permission help with patient support programs and access?
I give permission to J&J to receive, use, and share my Protected Health Information to:

See if I qualify for, sign me up for, contact me about, and provide services relating to J&J’s patient support programs. This includes in-home services
Manage J&J’s patient support programs
Give me resources and information related to my J&J medicine in connection with J&J’s patient support programs. This includes educational and adherence materials
Communicate with my Healthcare Providers about access, reimbursement, and fulfillment for my J&J medicine
Inform my Healthcare Provider that I am enrolled in J&J’s patient support programs
Help verify and coordinate coverage for J&J medicines with my Insurers and Healthcare Providers
Help with prescription or treatment location and associated scheduling
Conduct analysis to help J&J evaluate, create, and improve their patient support services and products for patients prescribed J&J medicines
Share information from J&J’s patient support programs that may be useful for my care

What should I understand before signing this Form?
I understand that:

J&J 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 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 in or receive assistance from J&J’s patient support programs
The following groups may be paid by J&J for their services and data, including Protected Health Information:

This Form will remain in effect 10 years from the date I signed below, except if:

Information collected before that date may continue to be used for the purposes noted in this Form

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

I am signing as parent or guardian (personal representative) of the patient.

Contact Information

Email Address

Patient Cell #

555-555-5555

Need Help?
Phone:
866-228-3546

Patient Information

Personal Representative Information

Contact Information