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 Herceptin Hylecta Access Solutions
- A copy of the Patient Consent Form
PAN=Patient Authorization and Notice of Request
for Transmission of Health Information to Genentech Access Solutions
and Genentech® Access to Care Foundation.