Enroll Into Genentech Patient Support Services
Get started with the Patient Consent Form. This form gives us permission to discuss your health information with others, such as your doctor and your health insurance plan, so we can help you.
You can submit this form in 1 of 3 ways:
Submit it online
Fill out and submit the form online using eSubmit for faster and easier enrollment
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)
You must sign and date the form to enroll into Genentech patient support services. People prescribed Evrysdi® (risdiplam) must complete and sign the patient consent section (page 4) of the Evrysdi Start Form. This form is different from the Patient Consent Form.
Forms
please note
Your doctor also has to fill out a form called the Prescriber Service Form. Once we have both of 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.