How to Apply

Step 1

Check to see if you’re eligible for the program or view eligibility requirements.

Step 2

Eligible? Get the application.

Patient Assistance
Application Form

or Call 800-652-6227
to have one mailed or faxed to you.

Step 3

Complete the application.

Read the application instructions carefully.
Complete and sign pages 2 and 3.
Include a copy of the front and back of your insurance cards(s).
Provide proof of income (Choose one): Check the box in section 5 on page 3 OR include a copy of your most recent 1040 or 1040-SR Federal tax return.

Step 4

Have your doctor complete and sign page 4 of the application.

Step 5

Submit completed application pages 2 thru 4 only with documentation to:

Fax: 888-526-5168 (toll free) or 740-966-1797 (direct dial)

Mail: Johnson & Johnson Patient Assistance Foundation, Inc.
Patient Assistance Program
P.O. Box 0367
Chesterfield, MO 63006

Next Steps

We will review your application

Once we receive your application, it will take about three days to review. If the application is missing information, it will take longer. Upon completion of review, we’ll send you a letter to let you know whether you’re eligible. When you apply, please be sure to include all your supporting documents.

If you’re approved

Depending on which medicine you need, you’ll be able to pick it up at your doctor’s office, a local or mail order pharmacy with your Pharmacy Card, or sent to your home. We’ll send you a letter that tells you exactly how you’ll receive your medicine.

You can reapply each year

Once approved, you’ll receive the medicines you need for up to one year. Before your enrollment ends, we’ll send you a reminder to renew your application for next year.