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Form from www. needymeds. org Reset Form Genentech Access to Care Foundation GATCF Confirmation of Infusion or Injection Phone 800 530-3083 - Fax 877 428-2326 This completed document is required to participate in the Genentech Access to Care Foundation GATCF free program. This form is available online via My Patient Solutions for applicable brands. Link to My Patient Solutions directly from Instructions All fields required* Complete this form after each infusion/injection and fax completed form to GATCF at the number listed above or submit through My Patient Solutions. Date of Service Amount Infused/Injected / mg Please complete sign and date the following statement. REQUIRED Print Patient Name Required Patient s Date of Birth Required Authorized HCP Signature Required Date of Signature Required Next Scheduled Infusion if applicable CERTIFICATION By signing above I certify that all information on this form is correct and this patient has been infused/Injected with product listed above. I know that GATCF could ask me for a copy of the patient s infusion/injection records for the purpose of an audit. I agree to provide a copy of the patient s legal remedies including seeking damages in litigation in the event GATCF determines that this certification is false or that the Confirmation of Infusion or Injection is false or inaccurate. Only the information requested on this form is required* Providing additional documents or information will delay processing* Only BioOncology products Rheumatology products and are supported by My Patient Solutions. The overseeing physician is accountable for the individual signing on the physician s behalf of the Health Care Professional HCP. Link to My Patient Solutions directly from Instructions All fields required* Complete this form after each infusion/injection and fax completed form to GATCF at the number listed above or submit through My Patient Solutions. Date of Service Amount Infused/Injected / mg Please complete sign and date the following statement. Date of Service Amount Infused/Injected / mg Please complete sign and date the following statement. REQUIRED Print Patient Name Required Patient s Date of Birth Required Authorized HCP Signature Required Date of Signature Required Next Scheduled Infusion if applicable CERTIFICATION By signing above I certify that all information on this form is correct and this patient has been infused/Injected with product listed above. REQUIRED Print Patient Name Required Patient s Date of Birth Required Authorized HCP Signature Required Date of Signature Required Next Scheduled Infusion if applicable CERTIFICATION By signing above I certify that all information on this form is correct and this patient has been infused/Injected with product listed above. I know that GATCF could ask me for a copy of the patient s infusion/injection records for the purpose of an audit. I know that GATCF could ask me for a copy of the patient s infusion/injection records for the purpose of an audit. I agree to provide a copy of the patient s legal remedies including seeking damages in litigation in the event GATCF determines that this certification is false or that the Confirmation of Infusion or Injection is false or inaccurate.

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