Get The Merck Access Program Enrollment Form Phone: 8552573932, Fax: 8557550518 The Merck Access

Filling out The Merck Access Program Enrollment Form is a critical step for individuals seeking assistance with their prescription medications. This guide provides clarity on each section of the form, ensuring users can complete it accurately and efficiently.

Follow the steps to complete the enrollment form effectively.

1. Click ‘Get Form’ button to access the enrollment form and open it for completion.
2. Please check the box next to the prescribed product(s). Carefully read the Medication Guides and follow up with your healthcare provider if you have questions.
3. Select the programs you wish to apply for, and complete the corresponding sections as instructed.
4. In Section 1, fill out 'Patient Information' with accurate personal details, including name, date of birth, address, and contact numbers.
5. If applicable, a legal representative should complete the 'Declaration of Legal Representative' section, including their signature.
6. Designate a 'Personal Representative' if needed, providing their contact information and relationship to the patient.
7. Provide 'Insurance Information' for all applicable types of insurance coverage, including policyholder details and include copies of insurance cards.
8. In Section 2, the patient or legal representative must authorize the use and disclosure of personal health information (PHI). Review and sign this section.
9. Complete Section 3 if you are applying for the Merck Patient Assistance Program, certifying all given information is accurate.
10. If applying for the Co-pay Assistance Program, complete Section 4 with your income details and certify your information.
11. Completion of the physician's certification is essential; ensure that the prescribing healthcare provider signs and dates the form.
12. Finally, review all entries for accuracy and completeness. Save the form, print a copy for your records, and fax it to 855-755-0518.

Complete your enrollment form online today for timely assistance with your prescribed medications.