Get Confirmation Of Infusion Or Injection

This guide provides clear, step-by-step instructions on how to accurately complete the Confirmation Of Infusion Or Injection form online, ensuring you can effectively participate in the Genentech Access to Care Foundation program. Users can confidently fill out their information, meeting all necessary requirements.

Follow the steps to complete your form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter the date of service in the designated field. This is the date when the infusion or injection occurred.
3. Fill in the amount infused or injected in milligrams (mg) next to the corresponding date of service.
4. If multiple infusions or injections occurred, complete the additional fields for the date of service and amount infused or injected as necessary.
5. Print the required patient name in the ‘Print Patient Name’ field. This section is mandatory.
6. Enter the patient's date of birth in the specified field to verify their identity.
7. The authorized healthcare professional must sign in the designated signature field to confirm the information provided is accurate.
8. Input the date of signature to document when the healthcare professional completed the certification.
9. If applicable, provide the date for the next scheduled infusion to assist in ongoing patient management.
10. Review all entries to ensure the accuracy and completeness of the form.
11. Once all fields are completed, save your changes, and choose to download, print, or share the completed form electronically or via fax to GATCF as instructed.

Start filling out your Confirmation Of Infusion Or Injection form online today for a seamless application process.