Get Patient Consent Form - Genentech Access Solutions

This guide provides clear instructions on completing the Patient Consent Form for Genentech Access Solutions. By following these steps, you can ensure your form is filled out accurately and submitted correctly, allowing you to receive the support you need.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to acquire the consent form and open it in your preferred editor.
2. Review the section titled 'About Your Consent' thoroughly, as it outlines how your personal information will be used and shared.
3. Fill in the patient information fields, including first name, last name, home phone, cell phone, date of birth, email, and preferred language. Make sure to mark all required fields with an asterisk (*) to avoid any submission issues.
4. If applicable, provide details for an alternate contact, including their full name and relationship to you.
5. In the signature section, you must sign and date the form on page 3. If you are completing the form on behalf of the patient, print your first and last name and indicate your relationship to the patient.
6. Complete the financial eligibility information section if applying for assistance through the Genentech Patient Foundation. Indicate your household size and annual household income.
7. If you choose to enroll in optional education and support services, sign and date the section demonstrating your consent.
8. After filling out all required fields and sections, save any changes you have made, and prepare to submit the form.
9. Send your completed form by either texting a photo of the last page to (650) 877-1111 or faxing it to (866) 480-7762. You can also complete this form online at Genentech-Access.com/PatientConsent.

Take the next step towards receiving support by completing your Patient Consent Form online today.