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Downloadable Forms

Check Request Form

This form is used to initiate the check reimbusement process. It is completed by the practice or pharmacy.

Electronic Funds Transfer (EFT) Authorization Form

This form is used to initiate the EFT registration process. It is a one-time registration completed by the practice.

Check Request Authorization Form

This form is used to initiate the check reimbursement process. It is a one-time registration completed by the practice.

Fax Consent Form

This form is used by the practice to give consent to receive fax communications from Genentech, Inc.

Questions about this program?

Call (855) MY-COPAY (855-692-6729)
9 a.m.–8 p.m. ET, Monday through Friday (except major holidays)

For questions about Genentech Oncology, please call (888) 249-4918.

Fax (877) 885-2607

Downloadable Forms

Check Request Form

Electronic Funds Transfer (EFT) Authorization Form

Check Request Authorization Form

Fax Consent Form

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