Downloadable Forms

Check Request Form

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

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 (844) HEM-COPAY (844-436-2672)
9 a.m.–8 p.m. ET, Monday through Friday (except major holidays)

For questions about HEMLIBRA, please call (866) HEMLIBRA (866-436-5427).

Fax (855) HEM-COPAY (855-436-2672)

Downloadable Forms

Check Request Form

Fax Consent Form

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