Get Merck Access Program Enrollment Form Zinplava (bezlotoxumab). Patients And Prescribers Can Download

Filling out the Merck Access Program Enrollment Form for ZINPLAVA can seem overwhelming, but this guide provides a clear and supportive path to ensure all necessary information is accurately submitted. Whether you are a patient or a prescriber, following these steps will help streamline the enrollment process.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it for completion.
2. Begin with the Patient Information section. Fill in the patient's name, date of birth, and complete address. Ensure the correct phone numbers are provided, including home and other contact numbers.
3. Fill out the Insurance Information section. Include front and back copies of the insurance cards, or indicate if the patient has no insurance. Provide details of the primary and any secondary insurance such as the plan name, policyholder information, and policy IDs.
4. In the Diagnosis/Treatment Information section, indicate the diagnosis codes and the anticipated administration date of ZINPLAVA. This is crucial for the evaluation process.
5. Complete the Physician Information section. Provide the name, tax ID, NPI number, and contact details of the prescribing physician as well as the administering facility if applicable.
6. Review and complete the Physician or Authorized Representative Signature and Declaration section. An original signature is required to confirm the integrity of the submission.
7. If applicable, complete the Patient Certification section. The patient or their legal representative must sign to indicate they understand the program's terms and that the information provided is accurate.
8. Lastly, ensure all necessary sections have been filled out. After reviewing the form for accuracy and completeness, users can save changes, download, print, or share the form as needed.

Complete the enrollment form online today to ensure access to the Merck Access Program for ZINPLAVA.