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Please fill in your practice information and agree to the Practice Agreement. Agreeing to the terms of this agreement is required in
order to proceed with My Patient Solutions.
All fields are required except 1) phone extensions 2) suite numbers and 3) NPI #
This My Patient Solutions Practice Agreement (“Agreement”) is entered into by and between the below-named legal entity (“Practice”) and Genentech USA, Inc. (“Genentech”) and shall be effective as of the date on which it is executed by Practice’s duly authorized representative (“Effective Date”). By signing this Agreement, Practice hereby agrees to abide by the Terms and Conditions of this Agreement.
This Agreement must be electronically signed and submitted to Genentech before the Practice may enroll in My Patient Solutions.
Read and acknowledge the terms and conditions listed below.
This Agreement sets forth the terms and conditions under which Practice may access and use My Patient Solutions. Violation of this Agreement may result in the termination of Practice’s access to and use of the information on My Patient Solutions and/or My Patient Solutions’ services immediately and without notice, in addition to other legal remedies available to Genentech.
Practice may access My Patient Solutions only to provide information to, and receive information from, Genentech Access Solutions related only to the patients for whom Practice is seeking reimbursement and patient assistance services (“Purpose”). Practice may not use My Patient Solutions for any other purpose. You are responsible for the accuracy of the data that you provide and Genentech Access Solutions declines any responsibility for false data in the system.
I have read and agree to the terms of the Practice Agreement
for My Patient Solutions.
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