Patient Authorization and Notice of Release of Information (PAN)

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You can fill out the PAN form here online or download a pdf to print out and mail (or fax) in to us.

Nutropin GPS is a free patient support program for you from Genentech.

We work to help you pay for your Genentech product. We can help in many different ways. We assist people who have a healthcare plan as well as those who don't.

If you don’t have a healthcare plan, or your plan won't pay for your Genentech products, we might be able to help by referring you to GATCF. If you meet certain financial and medical standards, GATCF can supply free medicine.

For us to help, we need to look at, use and disclose your personally identifiable information (PII). Your healthcare provider and healthcare plan can disclose your PII to us only with your written authorization. By signing this authorization form, you are authorizing your healthcare provider and healthcare plan to release your PII to us, and authorizing us to disclose your PII as necessary to perform services for you. Once you sign this form and it is sent back to us, or submitted electronically by you or by your healthcare provider on your behalf, we can start to provide these services. You can choose not to agree to this authorization, however, please note that we cannot provide our services without it. This means you might need to pay for certain medications on your own.

Please read through this form carefully. If you have any questions, talk to your healthcare providers’ office or call us at: 1-866-688-7674.

1. Information to Be Disclosed or Used

This signed form lets my healthcare providers and healthcare plans send my PII and this form electronically, to Nutropin GPS and/or GATCF. This includes:

  • All my health records relating to my treatment
  • Information about my healthcare plan benefits
  • The dollar balance left on the total of the lifetime payments covered by my healthcare plan policy (if this applies to my plan)
  • Any information having a bearing on my health or my adherence to my treatment

All of the above is considered part of my PII. I know this could include information about:

  • Sexually transmitted diseases
  • Mental health conditions
  • Genetic test results

2. Who May See And Use Personally Identifiable Information (PII)

My PII may be seen by Nutropin GPS and/or GATCF. Nutropin GPS is sponsored by Genentech. Its address is 1 DNA Way, Mail Stop #858a, South San Francisco, CA 94080-4990.

It may also be seen by anyone helping Nutropin GPS perform services including Genentech employees and any of Genentech’s partners, for the purpose of facilitating access to Genentech products. Genentech may share your PII with partners, and/or their agents and affiliates, and your healthcare provider and health plan.

My PII May Be Used Only In These Ways:

  • Helping with my healthcare plan coverage for Genentech products
  • Applying to GATCF
  • Determining eligibility for alternative forms of coverage and sources of funding
  • Coordination of prescription fulfillment through a pharmacy
  • Tracking my use of Genentech products
  • For Genentech, or our partners’ administrative purposes

3. Notices

This authorization and notice of release shall be in effect for five years from the date of my signature unless a shorter period is required by state law.

I understand that if I am a resident of the state of Maryland, this authorization will be valid for no longer than 1 year from the date I signed it.

Once I sign this form, I know my PII might not be covered by any federal law that restricts the use and disclosure of my PII. There is no guarantee my PII might not be released to a third party. This third party might not need to follow the conditions of this authorization and notice of release.

I know I can refuse to sign this form. I may withdraw authorization at any time and for any reason. This won’t affect the start or continuing of my treatment, the quality of my treatment, and will have no impact on my treatment by my healthcare provider. To withdraw it, I must send a written notice to Genentech. It can be sent by fax or by mail to the address on this page. This withdrawal goes into effect once it is received by Genentech. If I don’t sign this form or if I withdraw my authorization, Genentech will not be able to help me with access to my Genentech product(s).

I understand that I, as the patient or signer, have a right to obtain a copy of this signed authorization and notice of release during the time period this authorization is valid, or up to three years after it is signed.

4. Distribution Acceptance

If I receive free product from GATCF, I will use Genentech products as my healthcare provider has prescribed them to me. I will not sell or distribute Genentech products. I understand it is unlawful to do this. I am responsible for ensuring any Genentech product is sent to a secure address when it is shipped to me. I know it is my duty to control any Genentech product while it stays in my possession.

Acceptance of Disclosure

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I acknowledge that the last four digits of my Social Security number constitute an electronic signature. By placing my electronic signature on this agreement I expressly consent to use and rely on electronic agreements and signature and I understand my signature will have the same binding affect as if I was providing a handwritten signature.

If you meet certain financial and medical standards, Genentech Access to Care Foundation can supply free medicine. In order to assess your eligibility, please provide your total household income.

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I acknowledge that the last four digits of my Social Security number constitute an electronic signature. By placing my electronic signature on this agreement I expressly consent to use and rely on electronic agreements and signature and I understand my signature will have the same binding affect as if I was providing a handwritten signature.

If you meet certain financial and medical standards, we can supply free medicine. This done through the Genentech Access to Care Foundation. In order to assess your eligibility, please provide your total household income.

Please review the information below and submit. If you need to make any changes, please use the back button.

Please click "Submit" to submit the form.

I have read this document or have had it explained to me. By signing this form, i know I am authorizing the release and disclosure of my PII as discussed in this authorization form.

Today's date is Month DD, YYYY 12:00:00 PST

Thank you for your submission.

If you have any questions, please contact the Nutropin GPS team at

866-688-7674.

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