Forms and Documents

xolair prescriber service form

The Prescriber Service Form is filled out by the health care provider and is used to collect the patient’s health insurance and treatment information.

patient consent form

Patient Consent Form

The Patient Consent Form is filled out by the patient and gives permission for Genentech to work with the health care provider and the patient’s health insurance plan.

spanish patient consent form

Spanish Patient Consent Form (Formulario de Consentimiento del Paciente)

A version of the Patient Consent Form for your Spanish-speaking patients. Download Selected 0 files selected Files will be downloaded as .zip file.

Other Important Documents

Enrolling in the Genentech Patient Foundation

The Genentech Patient Foundation gives free Genentech medicine to people who don't have health insurance coverage or who have financial concerns and meet eligibility criteria. Two forms are needed to enroll in the Genentech Patient Foundation:

  1. Prescriber Foundation Form (to be completed by the health care provider).
  2. Patient Consent Form (to be completed by the patient).

Considerations for Composing a Letter of Medical Necessity

This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Considerations for Composing a Sample Appeal Letter

This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Recertification Reminder Program Enrollment Form

Use this form to enroll your practice in the XOLAIR Recertification Reminder Program for patient prior authorization reminder notifications.

Fax Cover Letter

Use this cover sheet when faxing documents to XOLAIR Access Solutions.

For assistance, call (877) GENENTECH/(877) 436-3683
6 a.m.–5 p.m. PT, Monday through Friday

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