All other Terms and Conditions for the Merck Co-pay Assistance Program remain in effect and must be satisfied to receive the benefit.
Please click on the links below to access The Merck Access Program forms that are applicable to you. If your patient is requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription for KEYTRUDA. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
sign & submit electronically
These forms can be signed and submitted electronically.
Patient in Office
Use this form if the patient is in the office and you are able to complete the form together.
Patient Not in Office
Use this form when the patient is not in the office to complete the form with you.
The patient must also submit the Electronic Patient Enrollment Form.