WELCOME TO
THE MERCK
ACCESS PROGRAM
ARE YOU A US HEALTH CARE PROFESSIONAL?
YES
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The information that you include on this form will be used only to populate the fields on this form. Your information will not be received, saved, or maintained by Merck until you have printed and faxed this form to The Merck Access Program.

Submit The Merck Access Program Enrollment Form

Print and fax the completed form to 855-755-0518.

For more information, please contact The Merck Access Program Mon-Fri at
855-257-3932, TTY: 855-257-7332.

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ENROLLMENT FORM

 

Phone: 855-257-3932, Fax: 855-755-0518, TTY: 855-257-7332  • The Merck Access Program, PO Box 29067, Phoenix, AZ 85038

PLEASE CHECK ALL BOXES THAT APPLY AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM

Patient Information Section
Patient information 1 of 6
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
Insurance information 2 of 6
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
Patient authorization3 of 6
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
The Merck Co-Pay Assistance Program 4 of 6
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
The Merck Patient Assistance Program (offered through the Merck Patient Assistance Program, Inc.) 5 of 6
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
Health Care Provider Information Section
Health care provider information 1 of 3
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my independent medical judgment for an FDA-approved indication. I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
Complete

Thank you for completing The Merck Access Program Enrollment Form; please print and fax this to 855-755-0518.

THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
 
 
 
To request an appointment with a Nurse Educator, please call 855-257-3932.