Forms and Documents

Here you can download the form you need to enroll in Esbriet Access Solutions and other important information. Please remember, your doctor also needs to fill out a form to enroll you.

Start Enrollment with the PAN Form

To enroll in Esbriet Access Solutions, you need to sign a form called the Patient Authorization and Notice of Release of Information or PAN form. You can find this form below.

SMN

The Statement of Medical Necessity, or SMN form, is a form filled out and submitted by your doctor after he or she prescribes a Genentech product. You do not have to fill out any information on this form. 

Questions and Considerations to Ask Your Doctor’s Office

This information packet contains a copy of the PAN form and a list of questions you might have that someone at your doctor's office might be able to answer after you have been prescribed a Genentech product.