Start Your Enrollment

Here you can download the form you need to enroll in Genentech Access Solutions.

Start Enrollment With the PAN Form

To get started, fill out a form called the PAN. You can complete the PAN form in 1 of 2 ways:

  • Fill out and submit the form online
  • 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 SMN. 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 SMN form.

If you have been prescribed VENCLEXTA™ (venetoclax), you must fill out the VENCLEXTA PAN. Please see VENCLEXTA Forms and Documents to download this form.

 

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.