Fax or Mail

Download and print the application.

Click on the button below to download the application. Please print a copy for the patient to complete and sign. You will need to sign page 3 of the application, and the patient will need to sign page 4.

Adobe Reader is required to download this application - visit adobe.com to download Reader.

You can complete the application in writing; please use a pen.

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

Please keep a copy for your records.