Forms and Documents
We've made enrollment simpler, faster and more intuitive with some key changes to our forms. The Prescriber Service Form and the Patient Consent Form are required for enrollment in Genentech Access Solutions. These forms replace the Statement of Medical Necessity (SMN) and the Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation (PAN).
To download multiple files at once, select the checkbox next to each file you would like to download from the list below then click Download Selected. Documents will be downloaded as a .zip file.
Esbriet Access Solutions Enrollment Forms
Other Important Documents
Considerations for Composing a Letter of Medical Necessity
This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.
FDA approval letter (Follow this link and search by the drug name)
Considerations for Composing a Sample Appeal Letter
This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.
FDA approval letter (Follow this link and search by the drug name)
Enrolling in the Genentech Patient Foundation
The Genentech Patient Foundation gives free medicine to people who don't have insurance coverage or who have financial concerns and to people who meet certain income criteria.
Esbriet Recertification Reminder Program Enrollment Form
Complete this form to enroll your patients in the Esbriet
Recertification Reminder Program to help avoid potential gaps in their
Esbriet therapy due to health insurance plan recertification
requirements.
Fax Cover Letter
Use this cover sheet when faxing documents to Esbriet Access Solutions.
