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The document is a Patient Consent Form from Genentech, outlining the steps for patients to access their medications and support services. It includes instructions for completing the form, sharing personal information for treatment assistance, and enrolling in optional educational programs. The form emphasizes the importance of patient consent for Genentech to use personal identifiable information (PII) to facilitate access to medications and support services.

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Click ‘Get Form’ to open the genentech form in the editor.
Begin by reading the 'About Your Consent' section carefully. This will provide you with essential information regarding your personally identifiable information (PII) and how it will be used.
Fill in your personal details in the 'Patient Information' section, including your first name, last name, phone numbers, date of birth, and email address. Ensure all required fields marked with an asterisk (*) are completed.
In 'Financial Eligibility Information', indicate your household size and annual income. This is crucial for determining eligibility for the Genentech Patient Foundation.
Sign and date the form in the designated areas. Remember that a signature is necessary for processing your request for support.
Once completed, submit your form by either texting a photo of it to (650) 877-1111, faxing it to (866) 480-7762, or completing it online at Genentech-Access.com/PatientConsent.

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What is the Genentech rebate program?

Eligible commercially insured patients who are prescribed a Genentech Oncology medicine for an FDA-approved indication can receive up to $25,000 in assistance per product per calendar year. For more information, see full program Terms and Conditions. Apply for drug co-pay assistance. Dont have an account?

What is Genentech Access Solutions?

Access Solutions is a program from Genentech and is committed to helping you understand your insurance coverage and options that might be able to help you pay for your Genentech medicine. Call (866) 422-2377 or visit Genentech-Access.com for more information.

What does Genentech produce?

Genentech is a biotechnology company dedicated to pursuing groundbreaking science to discover and develop medicines for people with serious and life-threatening diseases. Our transformational discoveries include the first targeted antibody for cancer and the first medicine for primary progressive multiple sclerosis.

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