Forms and Documents
Download the form you need to enroll in Genentech Access Solutions and a helpful guide to use when talking to your doctor's office.
Start Enrollment With the Patient Consent Form
To get started, fill out the Patient Consent Form. This form replaces the Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation (PAN).
You can complete this form in 1 of 3 ways:
- Fill out and submit the form online
- Sign a printed form, take a photo and text it to (650) 877-1111
- Sign a printed form and fax or mail it to us (or give it to your doctor's office to do so)
Your doctor also has to fill out a form called the Prescriber Service Form. Once we have both these forms, we can begin working with you and your doctor's office. You do not need to fill out anything on the Prescriber Service Form.
Treatment Cost Discussion Guide
This information packet includes:
- Questions to consider asking someone at your
doctor's office after you have been prescribed a Genentech
- Information on how to enroll in HEMLIBRA
- A copy of the Patient Consent Form
Important Safety Information & Indication
What it Treats
What is HEMLIBRA?
HEMLIBRA is a prescription medicine used for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adults and children, ages newborn and older, with hemophilia A with or without factor VIII inhibitors.
Important Safety Information
What is the most important information I should know about HEMLIBRA?
HEMLIBRA increases the potential for your blood to clot. Carefully follow your healthcare provider’s instructions regarding when to use an on-demand bypassing agent or factor VIII, and the dose and schedule to use for breakthrough bleed treatment. HEMLIBRA may cause serious side effects when used with activated prothrombin complex concentrate (aPCC; FEIBA®), including thrombotic microangiopathy (TMA), and blood clots (thrombotic events). If aPCC (FEIBA®) is needed, talk to your healthcare provider in case you feel you need more than 100 U/kg of aPCC (FEIBA®) total.
How should I use HEMLIBRA?
- Stop (discontinue) prophylactic use of bypassing agents the day before starting HEMLIBRA prophylaxis.
- You may continue prophylactic use of factor VIII for the first week of HEMLIBRA prophylaxis.
What should I know about lab monitoring?
HEMLIBRA may interfere with laboratory tests that measure how well your blood is clotting and may cause a false reading. Talk to your healthcare provider about how this may affect your care.
The most common side effects of HEMLIBRA include: redness, tenderness, warmth, or itching at the site of injection; headache; and joint pain.
These are not all of the possible side effects of HEMLIBRA. Speak to your healthcare provider for medical advice about side effects.
You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.