Forms and Documents
Download the form you need to enroll in Genentech Access Solutions.
Download the form you need to enroll in Genentech Access Solutions.
Start Enrollment With the Patient Consent Form
To get started, fill out the Patient Consent Form. You can submit this form in 1 of 3 ways:
Submit it online
Fill out and submit the form online using eSubmit
Text a photo
Sign a printed form, take a photo and text it to (650) 877-1111
Send it via fax
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.
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Patient Consent Form
The Patient Consent Form gives us permission to discuss your health information with others, such as your doctor and your health insurance plan, so we can perform our services.
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Formulario de Consentimiento del Paciente
El Formulario de Consentimiento del Paciente nos da permiso para analizar su información de salud con otras personas, como su médico y su plan de seguro médico, para que podamos prestar nuestros servicios.
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- Complete and submit a form electronically.
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Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
Please select medication to continue
- ACTEMRA® (tocilizumab)
- ALECENSA® (alectinib)
- Avastin® (bevacizumab)
- COLUMVI™ (glofitamab-gxbm)
- COTELLIC® (cobimetinib)
- ENSPRYNG® (satralizumab-mwge)
- Erivedge® (vismodegib)
- Evrysdi® (risdiplam)
- GAZYVA® (obinutuzumab)
- HEMLIBRA® (emicizumab-kxwh)
- Herceptin® (trastuzumab)
- Herceptin HYLECTA® (trastuzumab and hyaluronidase-oysk)
- KADCYLA® (ado-trastuzumab emtansine)
- LUCENTIS® (ranibizumab injection)
- LUNSUMIO™ (mosunetuzumab-axgb)
- OCREVUS® (ocrelizumab)
- PERJETA® (pertuzumab)
- PHESGO ™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky ™ (crovalimab-akkz)
- POLIVY® (polatuzumab vedotin-piiq)
- Pulmozyme® (dornase alfa) Inhalation Solution
- Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
- RITUXAN® (rituximab) for Oncology
- Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), or Pemphigus Vulgaris (PV)
- RITUXAN HYCELA® (rituximab/hyaluronidase human)
- ROZLYTREK® (entrectinib)
- SUSVIMO ™ (ranibizumab injection)
- TECENTRIQ® (atezolizumab)
- VABYSMO® (faricimab-svoa)
- VENCLEXTA® (venetoclax tablets)
- XOLAIR® (omalizumab) for subcutaneous use
- ZELBORAF® (vemurafenib)
OR SELECT
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