The Johnson and Johnson Patient Assistance enrollment form is a three-page application you and your prescriber complete together to request free J&J medication for up to one year through the Johnson & Johnson Patient Assistance Foundation (JJPAF). Download it from the J&J withMe portal at portal.jnjwithme.com/patient-assistance, fill out your section, have your doctor fill out theirs, attach proof of income, and fax the package to 833-512-0497.1Johnson & Johnson. Patient Assistance2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form If you get stuck, the foundation’s support line is 1-833-742-0791.
Where to Download the Form
The PDF lives on the J&J withMe portal and at asset.jnjwithme.com, and many prescriber offices keep printed copies behind the front desk.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form Page one is instructions, page two is yours, page three is your prescriber’s. Any field with an asterisk is required. Skip one and the application comes back.
Before You Start: Do You Qualify?
The foundation looks at three things: residency, insurance, and household income. You need to live in the United States or its territories. If your insurance already covers the J&J medication you need, you are not eligible — the program is built for people who are uninsured, underinsured, or on a plan that excludes the specific drug.
Income limits track the federal poverty guidelines published each year by the Department of Health and Human Services. For 2026, 100% of the Federal Poverty Level is $15,960 for a single person in the 48 contiguous states.3U.S. Department of Health and Human Services. 2026 Poverty Guidelines – Detailed Guidelines The actual ceiling the foundation uses varies by medication, so call 1-833-742-0791 to confirm the threshold for your drug before you spend time on paperwork.
If You Have Medicare Part D
Medicare Part D is not an automatic disqualifier, but you have to show two extra things. First, your household’s out-of-pocket prescription spending has to exceed 4% of gross annual household income, documented with a pharmacy spending report or an Explanation of Benefits from your insurer.4Johnson & Johnson. Johnson and Johnson Patient Assistance Program Quick Reference Guide Second, if your income is at or below 150% of the Federal Poverty Level, you also have to show that you were denied Medicare’s Low-Income Subsidy (Extra Help). You can apply for Extra Help through the Social Security Administration at any time.5Social Security Administration. Apply for Medicare Part D Extra Help Program A denial letter from Social Security becomes your documentation. One restriction worth knowing: you cannot seek reimbursement for the value of medications you receive through this program from any health plan, flexible spending account, or health savings account.
Filling Out Page 2 (The Patient Section)
Page two has five sections. Take them one at a time.
Section 1: Patient Information
Full legal name, primary phone, date of birth, sex, mailing address, and the exact name of the J&J product you are requesting. Check the product name against the list on the J&J withMe site. The foundation covers specific J&J medications, not every drug on the market.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Section 2: Insurance Information
Enter every plan you have: BIN number, policy number, group number, cardholder name and date of birth, and the cardholder’s employer. There are separate fields for primary prescription, primary medical, and secondary medical coverage. Fill this in honestly even if you believe your insurance will not cover the drug. The foundation verifies coverage on its own, and a blank insurance section when you actually have a plan can delay or sink your application.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Section 3: Financial Information
Report your total gross annual household income and your household size. Household size means you plus everyone who lives with you and depends on that income. This number is what the foundation compares to the Federal Poverty Level.
Sections 4 and 5: Consent and Authorization
Both sections ask you to print your name, sign, and date. Section 4 is your consent to participate. Section 5 authorizes the foundation to share your information with your prescriber and pharmacy to process the application. A legally authorized representative can sign for you if you cannot sign yourself.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Filling Out Page 3 (What Your Doctor Does)
Page three is your prescriber’s. This is where applications most often stall. If the office is busy, the form can sit on a desk for weeks. Hand-deliver or fax page three with a note about your timeline, then follow up a few days later.
Your prescriber completes three blocks:
- HCP information. Required: provider name, practice name, address, phone, fax, Tax ID, and NPI. DEA and state license numbers are optional but recommended. A nurse practitioner or physician assistant must list a collaborating physician and that physician’s NPI. Medicare patients also need the prescriber’s Provider Transaction Access Number (PTAN).2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
- Prescription information. ICD diagnosis code, product name, strength, sig (dosage instructions), quantity, day supply, number of refills (up to 11), need-by date, ship-to location, your allergies, and your current medications. The prescriber also marks whether this is a first-time fill.
- HCP authorization. The prescriber signs and dates. Without the signature, the application is rejected.
If the medication is SPRAVATO (esketamine), the prescription cannot be written on this form because it is a controlled substance. Your prescriber sends an electronic prescription directly to the designated specialty pharmacy instead.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Documents to Attach
Include a copy of your most recent federal tax return, Form 1040 or 1040-SR, as proof of income.6Johnson & Johnson. Johnson and Johnson Patient Assistance Enrollment Form The form does not list W-2s or 1099s as alternatives for residents of the 50 states. If you did not file a return, call 1-833-742-0791 before submitting to ask what else they will accept.
Puerto Rico residents can use the Puerto Rico Income Tax Return (Form 482), a Returns Filing Certification (Form AS 6088.1), or a Social Security Benefits statement (Form SSA-1099).2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Medicare Part D patients add the pharmacy spending report or Explanation of Benefits showing drug costs above 4% of gross household income, plus, if applicable, documentation that you were denied the Low-Income Subsidy.4Johnson & Johnson. Johnson and Johnson Patient Assistance Program Quick Reference Guide
How to Submit
Fax is fastest. Send the completed form and every supporting document to 833-512-0497. The fax line is open around the clock, and most prescriber offices already prefer this route.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
You can also enroll electronically through the J&J withMe portal at portal.jnjwithme.com/patient-assistance/enroll, and upload supporting documents at account1.jnjwithme.com/patient-assistance.7Johnson & Johnson. Patient Assistance – Enroll Mailing is available too, but the current form does not prominently publish an address. Call 1-833-742-0791 to confirm it before you send physical documents.
What Happens After You Submit
Once the foundation has a complete application, review takes about three business days. Missing information stretches that out, which is why checking every required field before you submit is worth the extra few minutes.8findhelp.org. Johnson and Johnson Patient Assistance Foundation, Inc. (JJPAF) – Patient Assistance Program You get an approval or denial letter, and the foundation also contacts your prescriber’s office.
Approved patients receive medication shipped directly to the ship-to location the prescriber selected: either your home or the provider’s office. Because the prescriber can authorize up to 11 refills on one enrollment, the foundation can keep sending medication without a fresh prescription for every fill.2Johnson & Johnson. Patient Assistance Program Patient Enrollment Form
Re-Enrolling Each Year
Program terms expire at the end of each calendar year and can change or end without notice, including in specific states.4Johnson & Johnson. Johnson and Johnson Patient Assistance Program Quick Reference Guide To keep receiving medication, submit a new enrollment form before your current term ends. The process is the same as the first time: updated income documentation, a current prescription, and fresh signatures. Start in the fall so there is no gap in deliveries at the start of the new year.