Acquisition and Administration InformationStep 6
Specialty pharmacy needed for Rituxan
®
(rituximab) or ACTEMRA
®
(tocilizumab) dispensing?
Yes
No (physician’s office will supply)
Preferred specialty pharmacy:
Place of infusion:
Prescribing physician’s office
Other physician’s office
Hospital outpatient
Other:
Infusion site name: Infusion site tax ID #:
Infusion site NPI
†
#: Street: Suite:
City: State: ZIP:
By submitting this form, I certify: (a) The above therapy is medically necessary for this patient and the treatment decision has been made by
the prescribing physician. (b) If the indication for which this Genentech product is being prescribed to treat is not listed in the FDA-approved
label, the prescriber is prescribing the medication for an “unapproved” use, meaning that the FDA has not approved the efficacy, dosage
amount or safety of this medication for such a use. (c) 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.,
Genentech Access Solutions, the contracted dispensing pharmacy, or other contractors for the purpose of requesting reimbursement support,
assisting in initiating or continuing therapy, as a break in treatment would negatively impact the patient’s therapeutic outcome. (d) The provider’s
office will not attempt to seek reimbursement for free product provided to the patient. (e) The services requested on behalf of the patient may
include benefits investigation (BI), prior authorization (PA) and appeals support, co-pay card and co-pay assistance foundation referral. (f) No action
on these services will be taken until the patient consent document has been received.
Health Care Provider CertificationStep 8
ACT Fast free starter supply only (ACTEMRA subcutaneous patients only)
Drug: ACTEMRA subcutaneous self-injectable 162-mg
Prefilled Syringe
Autoinjector (ACTPen
®
)
Dispense: 15-day supply
Once every week
Once every 2 weeks Patient weight:
lbs Refill times
Starter RequestStep 9
• If you are seeking support services for starter therapy or ACTEMRA subcutaneous, please continue by completing
the step below and providing a prescriber signature. Once signed and dated, fax pages 1 and 2 to (866) 681-3288
•
Otherwise, no signature is needed. Please fax pages 1 and 2 to (866) 681-3288
Patient Information (please re-enter)Step 5
*First name: *Last name: *Date of birth (MM/DD/YYYY):
/ /
Sign, date & fax to
(866) 681-3288
*Prescriber’s Signature: *Date:
Sign, date & fax to
(877) 313-2659
(Original or stamped signature required)
*Prescriber’s Signature:
*Date:
(Original or stamped signature required)
/ /
Prescriber InformationStep 7
*First name: *Last name:
*Practice name:
*Street: Suite: *City:
*State: *ZIP: Prescriber tax ID #:
Prescriber NPI
†
#: Group NPI
†
#:
Office contact: Contact phone: Contact fax:
)
)
-
)
)
-
for
®
& ACTEMRA
®
Prescriber Service Form
Required field (*) M-US-00006696(v1.0) 08/20
SUBMIT ONLY REQUESTED DOCUMENTS
†
National Provider Identifier.
Rituxan is a registered trademark of Biogen, Inc.
ACTEMRA and ACTPen are registered trademarks of Chugai Seiyaku Kabushiki Kaisha Corp., a member of the Roche Group.
The Access Solutions logo is a registered trademark of Genentech, Inc.
©2020 Genentech USA, Inc. So. San Francisco, CA All rights reserved.
Phone: (866) 681-3261
|
Fax: (866) 681-3288
|
Genentech-Access.com/Rituxan
|
Genentech-Access.com/ACTEMRA
|
M-US-00006696(v1.0) 08/20
2 of 2
(rituximab)
(tocilizumab)
