Patient Enrollment Form

Transcription

1 Patiet Erollmet Form 1 HEALTHCARE PROFESSIONAL (HCP) HCP Name Facility Name Address City State Zip Tel ( ) Fax ( ) HCP NPI# Facility Cotact(s)* * By icludig a facility cotact ame other tha the HCP, the HCP is authorizig the facility cotact to accurately relay HCP directios to JANSSEN CONNECT. The HCP will provide appropriate oversight to esure orders are accurately relayed ad that the HCP is iformed about all program iformatio relevat to the cliical care of the patiet. Facility Cotact Tel ( ) Facility Type: Ipatiet/Hospital Correctioal Outpatiet Cliic Telepsychiatry Private Practice Other 2 PRESCRIPTION Patiet Name DOB / / Sex: Male Female Patiet Address Pref. Laguage: Eglish Spaish City State Zip Other Tel ( ) Diagosis/ICD Code Is patiet ew to this medicatio? Please list ay kow drug allergies Yes No Check here if a copy of the prescriptio is attached ad sig below INVEGA SUSTENNA (paliperidoe palmitate) 39 mg, 78 mg, 117 mg, 156 mg, 234 mg Day 1 Dose mg IM Date Needed Day 8 Dose mg IM Date Needed Maiteace Dose mg IM every 4 weeks Date Needed #Refills Directios OR INVEGA TRINZA TM (paliperidoe palmitate) 273 mg, 410 mg, 546 mg, 819 mg Dose mg IM every 3 moths Date Needed #Refills Directios OR RISPERDAL CONSTA (risperidoe) 12.5 mg, 25 mg, 37.5 mg, 50 mg Dose mg IM every 2 weeks Qty Date Needed #Refills Directios SIGN HERE I certify that the above medicatio is medically ecessary ad that the iformatio provided is accurate to the best of my kowledge. By my sigature, I also ackowledge that I have obtaied the patiet s authorizatio to release the above iformatio ad such other iformatio as may be required by JANSSEN CONNECT to provide the offerigs selected. I appoit JANSSEN CONNECT, o my behalf, to covey this prescriptio to the dispesig pharmacy of the patiet s choice. I further certify that (a) ay offerig provided through JANSSEN CONNECT o behalf of ay patiet is ot made i exchage for ay express or implied agreemet or uderstadig that I would recommed, prescribe, or use JANSSEN CONNECT or ay other product or service for ayoe, ad that (b) my decisio to prescribe the products set forth o this page ad request JANSSEN CONNECT offerigs for my patiet was based solely o my determiatio of medical ecessity as set forth herei, ad that (c) I will ot seek reimbursemet for ay offerig provided by or through JANSSEN CONNECT from ay govermet program or third-party isurer. X / / X / / Dispese as Writte Date Substitutio Accepted Date X / / Supervisig Physicia Sigature Date Supervisig Physicia Name (if applicable) (prit ame) This prescriptio is oly valid if received by fax, meetig state regulatios. Commets: PAGE 1 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

2 3 4 5 Patiet Erollmet Form ALTERNATE PATIENT CONTACT (optioal) This cotact iformatio will be used to coordiate care services if the patiet caot be reached or is uable to maage his/her care. See full Patiet Authorizatio for JANSSEN CONNECT o page 3 of this erollmet packet for a full descriptio of what may be discussed with the alterate cotact listed below. Name Relatioship to Patiet Tel ( ) INSURANCE Primary Isurace Name Tel ( ) Cardholder Name Policy# Group# Check here if you re attachig a copy of the isurace card(s) If patiet has a separate prescriptio coverage pla, please list below. Prescriptio Pla Name Tel ( ) Policy Group# Bi# PCN# Istat Savigs Card: Please provide a Istat Savigs Card for my patiet. To the best of my kowledge, patiet has commercial isurace that covers medicatio costs ad is ot erolled i federal or state subsidized healthcare programs that cover prescriptio drugs, icludig Medicare, Medicaid, TRICARE, or ay other federal or state healthcare pla, icludig pharmaceutical assistace programs. We uderstad ad agree that a beefit verificatio will be performed ad a Istat Savigs Card will ot be provided if eligibility caot be verified Patiet requests that associated Istat Savigs Card iformatio be provided to pharmacy alog with their isurace iformatio if appropriate PROGRAM OFFERINGS Check the box ext to the offerigs you would like for your patiet. BENEFIT VERIFICATION Research my patiet s Jasse log-actig ijectable atypical atipsychotics coverage status Prior Authorizatio Form Assistace: By checkig this, I request that JANSSEN CONNECT assist my office i addressig the requiremets of this patiet s health pla related to prior authorizatio for treatmet with INVEGA TRINZA TM, INVEGA SUSTENNA, ad/or RISPERDAL CONSTA. I uderstad that assistace may iclude obtaiig the health-pla-specific prior authorizatio form, ad completig it based upo the patiet-specific iformatio provided o this form. I uderstad that the partially completed prior authorizatio form will be provided to my office by JANSSEN CONNECT for possible submissio to the health pla Prior Authorizatio Status Moitorig: By checkig this box, I request that JANSSEN CONNECT actively moitor the status of the prior authorizatio submissio. I request that JANSSEN CONNECT provide status updates to my office with respect to this PATIENT TRANSITION SUPPORT Provide iformatio ad assistace to help my patiet trasitio to the ext healthcare settig Facility Name Facility Cotact(s) Address Tel ( ) City State Zip Check this box if JANSSEN CONNECT should schedule patiet s iitial appoitmet, which icludes a remider alert MEDICATION SHIPMENT* Provide assistace i coordiatig my patiet s medicatio shipmet to my office Ship to HCP s secodary locatio at City State Zip *By selectig Medicatio Shipmet, I uderstad that Prior Authorizatio Status Moitorig will also be provided, if applicable INJECTION CENTER OPTIONS WITH REMINDER ALERTS* (if available i your geography) Fax me a list of available locatios Select a locatio closest to my patiet Cotact my patiet to select a locatio REMINDER ALERTS ONLY Please provide remider alerts for my patiets who will be receivig ijectios i my office Use the followig approved JANSSEN CONNECT locatio By amig the above locatio, I attest that I do ot have a fiacial relatioship with the ijectio ceter listed *By selectig Ijectio Ceter Optios, I uderstad that Prior Authorizatio Status Moitorig will also be provided, if applicable PAGE 2 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. My patiet s ext ijectio at my office is scheduled for: Date / / at : AM PM Jasse Pharmaceuticals, Ic May

3 Patiet Erollmet Form HIPAA Authorizatio for JANSSEN CONNECT I hereby authorize the use ad/or disclosure of my private health iformatio, described below, which icludes Protected Health Iformatio as defied i federal laws called the Privacy Regulatios developed uder the Health Isurace Portability ad Accoutability Act of 1996 (as ameded, HIPAA ). I geeral terms, I uderstad that Protected Health Iformatio is health iformatio that idetifies me or that could be used to idetify me. I uderstad that this authorizatio is volutary. The followig perso(s) or class of persos are authorized to disclose this iformatio: 1. Physicias or other healthcare providers that have provided treatmet or services to me. I uderstad that pharmacies that ship my medicatio may be paid to share this iformatio with JANSSEN CONNECT to help provide the offerigs requested for me. 2. The compay admiisterig JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). 3. My health pla or other third-party payer. 4. Physicias ad other healthcare providers as directed by the healthcare professioal erollig me i JANSSEN CONNECT. The followig perso(s) or class of persos are authorized to receive the iformatio: 1. JANSSEN CONNECT. 2. My health pla or other third-party payer. 3. Third parties that assist JANSSEN CONNECT with the provisio of patiet offerigs for JANSSEN CONNECT. Descriptio of the iformatio that may be used ad/or disclosed: My diagosis, prescribed therapy (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]), ad a descriptio of the patiet offerigs I have requested or received from JANSSEN CONNECT. I uderstad that the iformatio disclosed about me may iclude metal health iformatio ad/or records. The iformatio will be used ad/or disclosed for the followig purpose(s): 1. For the provisio of the JANSSEN CONNECT patiet offerigs requested, such as ivestigatig my prescribed therapy coverage status, assistig with uderstadig prior authorizatio or appeal requiremets, providig iformatio ad assistace to help my trasitio to my ext healthcare settig, assistig i coordiatig my medicatio shipmet, helpig me PAGE 3 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

4 Patiet Erollmet Form HIPAA Authorizatio for JANSSEN CONNECT (cotiued) determie additioal ijectio ceter optios, ad providig welcome ad remider alerts. 2. I respose to a court order, subpoea, or otherwise required by law. Redisclosure: I uderstad that the Protected Health Iformatio disclosed pursuat to this authorizatio may be redisclosed by JANSSEN CONNECT, for the purposes outlied above to my health pla(s) or other third-party payer(s), my healthcare providers, JANSSEN CONNECT cotractors, ad ay idividual I desigate as a alterate cotact, ad I specifically authorize such redisclosures. Rights ad Other Terms: 1. Iability to Coditio Treatmet, Paymet, Erollmet, or Eligibility for Beefits o Provisio of Authorizatio. I uderstad that my healthcare providers ad health pla(s) may ot coditio my treatmet, paymet, eligibility for beefits, or erollmet i the health pla upo my sigig this authorizatio. 2. Copy of Authorizatio. I uderstad that I am etitled to a siged copy of this authorizatio. 3. Expiratio of Authorizatio. I uderstad that this authorizatio shall expire either whe I stop receivig JANSSEN CONNECT patiet offerigs, or 10 years from the date of this authorizatio, whichever occurs first. 4. Right to Revoke Authorizatio. I uderstad that I may revoke (ie, take back) this authorizatio at ay time except to the extet the recipiets of my iformatio have already take actio i reliace o my authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: HIPAA. I uderstad that the persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. 6. Review Iformatio Disclosed. I uderstad that I have the right to review the iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date PAGE 4 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

5 Patiet Erollmet Form HIPAA Authorizatio for Marketig Activities I have erolled i the JANSSEN CONNECT program ad have authorized certai health iformatio about me to be disclosed to the compay that admiisters JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). This health iformatio ( Persoal Iformatio ) icludes iformatio about: My diagosis. The therapy prescribed to me (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]). The patiet offerigs I have received from JANSSEN CONNECT. This Persoal Iformatio may reveal metal-health-related iformatio about me. I ow hereby authorize JANSSEN CONNECT to use my Persoal Iformatio to: Sed me educatioal ad marketig materials regardig the JANSSEN CONNECT program, my prescribed therapy, ad other related products or offerigs i which I might be iterested. Cotact me to obtai feedback about Jasse Pharmaceuticals, Ic., Uited BioSource Corporatio or aother admiistrator of the program, the JANSSEN CONNECT program, ad my prescribed therapy. Maage ad improve the JANSSEN CONNECT program. Respod to a court order, subpoea, or as otherwise required by law. This iformatio ad cotact may occur by phoe, text, , or postal mail uless I request otherwise from JANSSEN CONNECT. I uderstad that JANSSEN CONNECT will oly share my Persoal Iformatio with third parties that provide support for JANSSEN CONNECT pursuat to cotracts where those third parties agree to use the iformatio oly as described i this authorizatio, or as required by law or legal process. I uderstad that, with respect to this authorizatio: I sig this authorizatio volutarily. I uderstad that I may refuse to sig this authorizatio. I uderstad that JANSSEN CONNECT will receive paymet from Jasse Pharmaceuticals, Ic., for providig me with the iformatio ad materials described i this authorizatio. I am etitled to a siged copy of this authorizatio for my records. I may revoke this authorizatio i writig at ay time, except to the extet that actio has already bee take i reliace upo this authorizatio, ad PAGE 5 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

6 Patiet Erollmet Form HIPAA Authorizatio for Marketig Activities (cotiued) if ot earlier revoked, this authorizatio will termiate o the sooer of (i) whe I stop receivig JANSSEN CONNECT patiet offerigs, or (ii) 10 years from the date of this authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: I uderstad that ay revocatio will ot apply to iformatio that has already bee used ad released i respose to this authorizatio. The persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. I uderstad that I have the right to review ay iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date Patiet PAGE 6 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

7 Patiet Erollmet Form HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer I have erolled i the JANSSEN CONNECT program ad have authorized certai health iformatio about me to be disclosed to the compay that admiisters JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). This health iformatio ( Persoal Iformatio ) icludes iformatio about: My diagosis. The therapy prescribed to me (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]). The patiet offerigs I have received from JANSSEN CONNECT. This Persoal Iformatio may reveal metal-health-related iformatio about me. I ow hereby authorize JANSSEN CONNECT to disclose this Persoal Iformatio to my health pla ad its affiliates for purposes of: My case maagemet ad care coordiatio. The health pla s ow data aalysis, icludig to help my health pla to uderstad how I ad others have used the JANSSEN CONNECT program, ad how the JANSSEN CONNECT program has impacted my healthcare ad the care of others participatig i the JANSSEN CONNECT program ad the cost of such healthcare. I uderstad that my health pla may create reports that do ot idetify me to share with JANSSEN CONNECT. I uderstad that JANSSEN CONNECT will ot share my Persoal Iformatio with ay other party for these purposes, except cotractors who provide support for JANSSEN CONNECT pursuat to cotracts where those cotractors agree to use the iformatio oly as described i this authorizatio, or as otherwise required by law. I uderstad that, with respect to this authorizatio: I sig this authorizatio volutarily. I uderstad that I may refuse to sig this authorizatio. I am etitled to a siged copy of this authorizatio for my records. I may revoke this authorizatio i writig at ay time, except to the extet that actio has already bee take i reliace upo this authorizatio, ad if ot earlier revoked, this authorizatio will termiate o the sooer of (i) whe I stop receivig JANSSEN CONNECT patiet offerigs, or (ii) 10 years from the date of this authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: I uderstad that ay revocatio will ot apply to iformatio that has already bee used ad released i respose to this authorizatio. PAGE 7 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

8 Patiet Erollmet Form HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer (cotiued) The persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. I uderstad that I have the right to review ay iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date PAGE 8 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

9 Disclaimer: Iformatio ad assistace (eg, iformatio regardig access ad reimbursemet, the ipatiet/ outpatiet appoitmet gap, medicatio shipmet, additioal ijectio ceter optios, ad followthrough of healthcare professioal-directed treatmet pla) are provided by Uited BioSource Corporatio ( UBC ), uder cotract for Jasse Pharmaceuticals, Ic. ( JPI ). A Patiet Erollmet Form, with sectios completed for requested iformatio regardig assistace, must be submitted to UBC by the healthcare professioal ( HCP ) i order to activate ay JANSSEN CONNECT assistace. No other forms for request for access to JANSSEN CONNECT will be accepted. Assistace caot be directly requested by the patiet. JANSSEN CONNECT is ot available to patiets participatig i a Patiet Assistace Program. The availability of iformatio ad assistace may vary based o geography. UBC provides iformatio to HCPs regardig whether the treatmet is covered by the applicable thirdparty payer, based o the payer s coverage guidelies ad the patiet iformatio provided by the HCP. This iformatio ad assistace are made available as a coveiece to patiets, ad there is o requiremet that patiets or HCPs use ay JPI or other Johso & Johso product i exchage for this iformatio or assistace. Third-party reimbursemet is affected by may factors. This documet ad the iformatio ad assistace provided by JANSSEN CONNECT are preseted for iformatioal purposes oly. They do ot costitute reimbursemet or legal advice. JANSSEN CONNECT does ot promise or guaratee coverage, levels of reimbursemet, or paymet. Similarly, all CPT* ad HCPCS codes are supplied for iformatioal purposes oly ad represet o statemet, promise, or guaratee expressed or implied by JPI or UBC that these codes will be appropriate or that reimbursemet will be made. The fact that a drug, device, procedure, or service is assiged a HCPCS code ad a paymet rate does ot imply coverage by the Medicare program, but idicates oly how the product, procedure, or service may be paid if covered by the Medicare program. Laws, regulatios, ad policies cocerig reimbursemet are complex ad are updated frequetly. Accordigly, the iformatio may ot be curret or comprehesive. JPI ad UBC strogly recommed you cosult your payer for its most curret coverage, reimbursemet, ad codig policies. UBC ad JPI make o represetatios or warraties, expressed or implied, as to the accuracy of the iformatio provided. I o evet shall UBC or JPI, or their employees or agets, be liable for ay damages resultig from or relatig ay iformatio provided by or access to or through JANSSEN CONNECT. All HCPs ad other users of this iformatio agree that they accept resposibility for the use of this program. JPI assumes o resposibility for ad does ot guaratee the quality, scope, or availability of the iformatio ad assistace provided (eg, iformatio regardig access ad reimbursemet, the ipatiet/outpatiet appoitmet gap, medicatio shipmet, additioal ijectio ceter optios, ad follow-through of HCP-directed treatmet pla). UBC, ot JPI, is resposible for the iformatio ad assistace it provides uder this program. Each HCP ad patiet is resposible for verifyig or cofirmig ay iformatio provided by UBC or JPI. All claims ad other submissios to payers should be i compliace with all applicable requiremets. *CPT Curret Procedural Termiology, copyright of the America Medical Associatio, Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

10 Patiet Erollmet Form FAX DATE PAGES SUBJECT JANSSEN CONNECT PATIENT ENROLLMENT FAX# PHONE# FROM FAX# Please fid the followig attached: Page 1... Healthcare Professioal (HCP) Iformatio ad Prescriptio (REQUIRED) Page 2... Patiet Isurace Iformatio ad Program Offerigs (REQUIRED) Pages HIPAA Authorizatio for JANSSEN CONNECT (REQUIRED) Pages HIPAA Authorizatio for Marketig Activities Pages HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer Jasse Pharmaceuticals, Ic May