Patient Consent Form for Genentech Services
This file includes a patient consent form for Genentech services. It guides patients on getting health insurance coverage, receiving optional education material and enrolling in assistance programs. The file includes detailed instructions, terms, conditions, and the authorization to use and disclose personal information.
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How do I fill this out?
To fill out this form, follow the instructions carefully. Ensure that you read the authorization details before signing. Make sure to sign and date the form to receive support from Genentech Access Solutions.
How to fill out the Patient Consent Form for Genentech Services?
1
Read the authorization details on pages 2 and 3.
2
Sign and date the form on page 4.
3
Choose a submission method: online, text, or fax.
4
Submit the completed form.
5
Contact Genentech Access Solutions at (866) 422-2377 for any questions.
Who needs the Patient Consent Form for Genentech Services?
1
Patients prescribed Genentech medicine who want insurance coverage assistance.
2
Individuals who want to receive educational material about their disease.
3
Patients eligible for the Genentech Patient Foundation program.
4
Uninsured individuals requiring Genentech medications.
5
Patients who need help with out-of-pocket costs for their treatment.
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What are the instructions for submitting this form?
Submit the completed form using one of the following methods: Complete online by scanning the QR code or visiting Genentech-Access.com/PatientConsent; Print, complete, take a photo, and text it to (650) 877-1111; Print, complete, and fax it to (866) 480-7762. Contact Genentech Access Solutions at (866) 422-2377 for any questions. Ensure all required fields are filled out and the form is signed and dated before submission.
What is the purpose of this form?
The purpose of this form is to provide patients with the necessary steps to gain access to Genentech services. By filling out this form, patients can learn about their health insurance coverage, receive educational material about their disease, and apply for assistance programs such as the Genentech Patient Foundation. This form ensures that patients receive the medications prescribed by their doctors without financial or coverage-related obstacles.
Tell me about this form and its components and fields line-by-line.
- 1. Personal Information: Includes the patient's contact information and demographic details.
- 2. Insurance Information: Details about the patient's health insurance coverage.
- 3. Authorization: Consent sections where the patient authorizes the use and sharing of their personal information.
- 4. Signature: The patient's signature and date, required for form completion.
- 5. Alternate Contact: Details of an additional contact person if needed.
What happens if I fail to submit this form?
If you fail to submit this form, you will not be able to receive the support and assistance provided by Genentech Access Solutions.
- No Assistance: You will not receive help with insurance coverage or co-pay assistance.
- No Educational Resources: You will not have access to optional educational material about your disease.
- No Medication Support: You may face difficulties in obtaining your prescribed medication.
How do I know when to use this form?
- 1. To Get Insurance Coverage Assistance: When you want to understand or verify your insurance coverage for Genentech products.
- 2. To Receive Educational Material: When you wish to sign up for disease education and related resources.
- 3. To Apply for Assistance Programs: When you want to apply for financial assistance and the Genentech Patient Foundation program.
- 4. To Add an Alternate Contact: When you need to designate an additional contact person.
- 5. To Give Consent for Data Use: When you need to authorize the use and sharing of your personal information by Genentech.
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You can share your completed PDF via email or by downloading it.
Do I need to fill out the form to get assistance?
Yes, completing and submitting the form is necessary for receiving support.
Is there a way to add additional contacts?
Yes, the form allows you to add alternate contacts.
How can I submit the form?
You can submit the form online, via text, or fax.
What if I need help filling out the form?
You can contact Genentech Access Solutions for assistance.
Will my information be secure?
Genentech ensures the privacy and security of your sensitive information.
How long is the authorization valid?
The authorization is valid for 6 years from the date signed.
Where can I find more information about my privacy rights?
You can find detailed information in Genentech's privacy policy on their website.
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