Forms and Documents
To enroll your patient in Pulmozyme® Access Solutions, please complete the forms described below. Then fax them to us at (800) 963-1792. Each form is an Adobe® Reader® PDF document. You may type in the form on your computer and print it out, or you may print it out and write in the needed information.
Statement of Medical Necessity (SMN) Form
The SMN is needed to refer your patient to Pulmozyme Access Solutions and the Genentech® Access to Care Foundation (GATCF). It may also be used to request a prior authorization if you are doing this with Pulmozyme Access Solutions. The physician must sign and date the SMN.
Patient Authorization and Notice of Release of Information (PAN) Form
The PAN is a form each patient signs for Pulmozyme Access Solutions or GATCF. The PAN lets Pulmozyme Access Solutions look at your patient's health records. We use this information for the purpose of helping with reimbursement, assisting with appeals or finding other help for eligible patients. The SMN must be faxed with the PAN for processing.
Fax Cover Sheet
For your convenience, we have provided a fax cover sheet with the contact information already completed. You may use this when you are enrolling a patient in Pulmozyme Access Solutions or GATCF.
Medicare Appointment of Representative (AOR)
If your patient would like you to assist with an appeal, Medicare may require this form. This form needs to be completed by you and the patient.
Pulmozyme (dornase alfa) Inhalation Solution Important Information
Indication and Usage
Daily administration of Pulmozyme in conjunction with standard therapies is indicated in the management of cystic fibrosis (CF) patients to improve pulmonary function. In patients with an FVC 
40% of predicted, daily administration of Pulmozyme has also been shown to reduce the risk of respiratory tract infections requiring parenteral antibiotics.
Safety and efficacy of daily administration have not been demonstrated in patients for longer than 12 months.
Important Safety Information
Pulmozyme should not be used in patients who are allergic to any of its ingredients. Pulmozyme should be used in conjunction with standard therapies for CF. When starting Pulmozyme therapy, patients may experience change in or loss of voice, discomfort in the throat, chest pain, red watery eyes, rash, dizziness, fever, or runny nose. These side effects are usually mild and short-lived.
For further information, please see the Pulmozyme full Prescribing Information. If you have questions, please discuss them with your CF health care team.
Pulmozyme® is a registered trademark and the Access Solutions logo and the Access Solutions Treatment made possible logo are trademarks of Genentech USA, Inc.
