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 get started, fill out a form called the PAN. You can find this form below.
Your doctor also has to fill out a form called the SMN. Once we have both these forms, we can begin working with you and your doctor’s office. You do not have to fill out any information on this form.
Questions and Considerations to Ask Your Doctor’s Office
This information packet includes:
- A copy of the PAN form
- A list of questions you might have
Someone at your doctor's office might be able to answer these questions after you have been prescribed a Genentech medicine.
PAN=Patient Authorization and Notice of Request
for Transmission of Health Information to Genentech Access Solutions
and Genentech® Access to Care Foundation.
SMN=Statement of Medical Necessity.