Patients & Caregivers » Apply by Fax or Mail

Download and print the application.

Click on the button below to download and print the application. 

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Complete the application.

Be sure to complete all parts of the application and do not leave blank spaces (use N/A if the space does not apply to you). Please sign the Patient Declaration and Authorization (page 4). We are unable to process applications without a patient signature.

Gather required documentation.

Please be sure to collect all the documents that are needed to apply for the program.

• All four pages of the application
• Copy of most recent federal tax return (as applicable)

Bring the completed application to your healthcare provider's office.

Your provider will need to complete all sections on page 2 (Products to Be Distributed) and page 3 (Physician Information) of the application. They must also sign the application. We recommend that both you and your provider keep a copy of the application for your records.

Mail or fax the completed application to the program.

Please submit all four pages of the completed and signed application, along with the tax return (if applicable).

Johnson & Johnson Patient Assistance Foundation, Inc.
Patient Assistance Program
P.O. Box 221857
Charlotte, NC 28222-1857

Or fax the documents to 1-888-526-5168

Completed applications are generally reviewed within a few days. Applications with missing information will cause delays. You will receive a letter letting you know whether or not you are eligible for the program.