Patient Assistance Program Application - Johnson and Johnson Patient 2025

1. Click ‘Get Form’ to open the Patient Assistance Program Application in the editor.
2. Begin by filling out the Patient Financial Statement on page 1. Ensure you provide your name, medical record number, and social security number accurately.
3. On page 2, detail your Monthly Household Income. List all sources of income before taxes, including employment, social security, and any other benefits.
4. Complete Appendix A to verify North Carolina residency. Attach one document from the provided list that confirms your residency status.
5. If applicable, fill out Appendix B for a Statement of Assistance if you have no income. Ensure it is signed and dated by the person providing support.
6. Sign and date each required page of the application where indicated. Review all information for accuracy before submission.
7. Return the completed application along with required documents within the specified time frame using the provided postage-paid envelope or fax number.

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