Genentech takes the health and safety of our patients, customers, employees and local communities very seriously, and we are actively responding to the global COVID-19 pandemic. For more, please visit our COVID-19 response page or call 1-877-436-3683.

Apply For Help

Health Care Providers

If you are a health care provider, click below to learn how to apply online or via fax.

Apply Now
Patients

If you are a patient, click below to learn how to begin your application process.

Apply Now
Contact Us

If you have questions about the application process, a foundation specialist is ready to help.
Call: (888) 941-3331
M-F, 6 a.m.–5 p.m.

Call a Specialist

Please Note: At this time, Genentech supports Evrysdi, Nutropin, Cellcept, Valcyte, and Fuzeon through a separate process.

Learn more about these support programs

Health Care Providers

Health Care Providers can submit the completed Patient Consent and Prescriber Foundation form in two ways:

Option 1: Submit forms online

If your practice has a registered account for My Patient Solutions, you can get started by logging into your account.

Log into My Patient Solutions.

Don't have an account?

Step 1: Ask your patient to complete the online Patient Consent Form, which is available in English and Spanish:
Patient Consent Form | Formulario de Consentimiento del Paciente

Step 2: Complete the online Prescriber Foundation Form.

Option 2: Print forms and fax or text

Step 1: Print the Patient Consent Form for your patient to complete.

Step 2: Print and complete the Prescriber Foundation Form.

Step 3: Submit the completed forms via fax or text.

Send via fax to 833-999-4363

Text a photo of the form to 
650-877-1111

Both forms are required. No action can be taken until a completed Patient Consent Form and Prescriber Service Form have been received.

The request will be processed within 5 business days upon receipt of both required forms and your office will be contacted to discuss the application outcome and any next steps

Patients

Step 1: Complete the online Patient Consent Form, which is available in English and Spanish:
Formulario de Consentimiento del Paciente

Step 2: Once you have completed the Patient Consent form, you can inform your doctor's office and let them know that you are applying for assistance from the Genentech Patient Foundation.

Your doctor will have to complete another form called the Prescriber Foundation Form. Both forms are required. No action can be taken until a completed Patient Consent Form and Prescriber Form have been received.