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Forms and Documents

Enrollment forms and other important documents can be found below. To use Quick Enroll for the Prescriber Service Form, select eSubmit.

XOLAIR Access Solutions Enrollment Forms

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  • Complete and submit a form electronically.

Other Important Documents

Enrolling in the Genentech Patient Foundation

The Genentech Patient Foundation gives free Genentech medicine to people who don't have insurance or who have financial concerns and meet eligibility criteria. Two forms are needed to enroll in the Genentech Patient Foundation:

  1. Prescriber Foundation Form (to be completed by the health care provider).
  2. Patient Consent Form (to be completed by the patient).

For more information, visit GenentechPatientFoundation.com.

 

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)

Prescribing Information

Sample coding for XOLAIR

 

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)

Prescribing Information

Sample coding for XOLAIR

 

Fax Cover Letter

Use this cover sheet when faxing documents to XOLAIR Access Solutions.

phone

For assistance, call (877) GENENTECH/(877) 436-3683
6 a.m.–5 p.m. PT, Monday through Friday

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