Get Corp-1083762-0004.indd

Filling out the CORP-1083762-0004.indd form online is an essential step to enroll in the Merck Patient Assistance Program. This comprehensive guide will walk you through each section of the form, ensuring you provide the necessary information accurately and clearly.

Follow the steps to complete your enrollment successfully.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin by filling out Section 1, which requires accurate patient information. Ensure you print in legible capital letters and provide details such as the patient’s first name, middle initial, last name, address, phone number, date of birth, and email address for acknowledgment.
3. Indicate the household's annual gross income and check the applicable sources of income. Be sure to answer whether the patient has insurance or other prescription drug coverage, and select all relevant options.
4. Specify the shipping preference for the prescribed product. You can choose either 'My Home' or 'My Physician's Office'.
5. Read and complete the patient declarations and authorizations carefully. It is crucial to certify that all provided information is accurate and understand the implications of the declarations.
6. Proceed to sign and date the form in the designated area provided in Section 1. Ensure the signature is original and written in ink.
7. If you are a physician or prescriber, fill out Sections 2 and 3, which require prescription and product information. Provide patient details again, as well as your own professional information and signature.
8. Before finalizing, review the form to confirm all information is complete and clear. Check both sides of the form for any missing details.
9. Once you have filled out the form, you can save changes, download, print, or share the form as needed before submitting it through mail.

Start filling out the CORP-1083762-0004.indd online today to access your enrollment benefits!