If you qualify, one simple form is all you need to apply to the Genentech Patient Foundation.
Learn more about these support programs here.
The Genentech Patient Foundation Enrollment Form includes important information for patients and health care providers. Both the patient and the health care provider need to review and sign the enrollment form. The form includes specific instructions on how to apply and where to fax the completed enrollment form. Please visit the See If You Qualify page for more information on eligibility prior to completing the form.
Fax the Enrollment Form to (833) 999-4363.
You can expect to hear from a Foundation Specialist to let you know if the application was approved or if we need more information.
Once the application is approved, we’ll send the Genentech medicine to the patient or the health care provider’s office as directed on the form as quickly as possible.