1. 2. 3. - Genentech Access
Your personally identifiable information (PII) may include: • Name and birthdate • Address, telephone number and email address • Important financial information, as necessary Who may see and use my PII I authorize Genentech and/or Genentech Patient Foundation to (i) use my PII for the purpose of facilitating my access to
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Prescriber Service Form forXOLAIR SUBMIT ONLY REQUESTED ...
www.genentech-access.comIf insured, please fill out the information below or attach a copy of the patient’s health insurance cards. ... The provider’s office received the authorization to release the information above and other protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) to Genentech, Inc ...
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