Practice Forms and Documents

Find the enrollment forms you'll need to help patients access GAVRETO after it's been prescribed, including for coverage, reimbursement and financial assistance services. There are also tips for composing a letter of medical necessity and appeal letter.

To learn more about the resources available to help your practice, including information on benefits investigations and prior authorizations, go to Helpful Resources for Your Practice.

Quick Links

GAVRETO Access Solutions Enrollment Forms

GAVRETO Access Solutions can help your patients better understand their coverage, find financial assistance options, learn how to get GAVRETO, understand which specialty pharmacy their health insurance plan requires, reverify coverage if needed and enroll in additional support options in the event of a coverage delay.


Prescriber Service Form

This form is used to collect the patient’s health insurance and treatment information for enrollment in GAVRETO Access Solutions.


Patient Consent Form 

This form is signed and dated by your patient, giving written permission for GAVRETO Access Solutions to discuss their health information with you and the patient's health insurance plan.

Genentech Patient Foundation Enrollment Forms

The Genentech Patient Foundation provides free GAVRETO to people who don’t have insurance coverage or who have financial concerns and meet eligibility criteria.

The following forms are needed for applying for assistance from the Genentech Patient Foundation. Learn more about the Genentech Patient Foundation and other resources programs.


Prescriber Foundation Form

Includes patient, insurance and prescription information. Page two must be completed and submitted by the prescriber.


Patient Consent Form

This form is signed and dated by your patient, giving written permission for GAVRETO Access Solutions to discuss their health information with you and the patient's health insurance plan.

Tips for Composing Letters of Medical Necessity and Appeal

Letter of Medical Necessity

This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference.

Appeal Letter

This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference.

Appeals

Use the links below to find additional information to enclose in your letter of medical necessity or appeal letter:

Financial Assistance
Financial support

Learn more about GAVRETO patient financial and practice resources.

Contact a Representative
Contact a representative

Contact your local representative for more information about GAVRETO.