Get Merck Patient Assistance Program

The Merck Patient Assistance Program is designed to provide support to individuals who require assistance accessing necessary medications. This guide will help you navigate the online enrollment form, ensuring that you can complete it accurately and efficiently.

Follow the steps to complete the enrollment form.

1. Press the ‘Get Form’ button to acquire the form and open it for editing.
2. Complete Section 1 with your personal information. Enter your first name, middle initial, last name, address, apartment number, city, state, phone number, zip code, date of birth, and gender. Ensure all fields are legibly filled out using capital letters.
3. Indicate whether you are a US resident and provide your current annual gross household income. Check all applicable sources of income and respond regarding prescription coverage.
4. Specify where you would like your medication shipped to by selecting either your home or your physician’s office and completing any necessary fields, such as insurance carrier information.
5. Read and sign the applicant declarations and authorization, confirming that the provided information is accurate and that you grant permission for your health information to be used as necessary.
6. After filling out your part, make sure your physician completes Sections 2 and 3, including signing the required areas.
7. Review the completed form to ensure all sections are filled out correctly. Consider saving changes, downloading, or printing the completed form for your records.
8. Finally, mail the completed enrollment form to the designated address, ensuring that everything is enclosed correctly.

Begin filling out the MERCK Patient Assistance Program enrollment form online today to secure the assistance you need.