Applying for Endowment Assistance
The patient or patient's representative may call the Endowment at 1-800-297-5557 at any time during the application process.
Applicant information
The patient or patient's representative should complete the Patient Information sections of the application.
Download Patient Application Information
Required documentation
Please submit a copy of the following information with your application.
- Income verification for all sources of household income. This may include:
- Copy of your most recent federal tax return (if you or other members of your household are required to file)
- Statement of Social Security benefits (copy of award letter, check or recent bank statement indicating monthly benefit amount)
- Statement of short and/or long term disability benefits
- Statement of alimony and/or child support received
- Unemployment benefits
- A copy of your insurance card(s) and insurance denial for Pulmozyme , if applicable. Please provide copies of both the front and back of your insurance card(s).
Physician information
The physician prescribing PulmozymeŽ therapy should complete the Physician Information sections of the application.
Download Physician Application Information
Review
Applications will not be processed until the Endowment has received a complete application including patient information, supporting documentation, and signed physician information.
Notification
Applicants and their physicians will be notified in writing of the eligibility determination.
Start and level of support
Support begins once an application is approved; it is not retroactive. Additionally, the level of support provided is based on pre-established criteria applied to application information. Eligibility for continued support will be re-verified periodically, and all applications must be renewed annually.
Confidentiality
All information provided to the Endowment is confidential.
Applications and supporting documentation can be mailed or faxed to:
The Genentech Endowment for Cystic Fibrosis
PO Box 222157
Charlotte, NC 28222-2157
Fax: 1-704-357-0036
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