Get We're Working To Keep Medicine Within Your Reach

This guide provides step-by-step instructions on how to fill out the We're Working To Keep Medicine Within Your Reach form online. It aims to assist users in understanding the application process for the Merck Patient Assistance Program.

Follow the steps to complete your application successfully.

1. Click the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. Begin by filling out Section 1, which requires the patient information. Ensure all fields are completed in legible print, including your first name, last name, address, date of birth, and email contact information.
3. For income verification, Section 2 needs to be completed. Sign and date the authorization allowing the Merck Patient Assistance Program to verify your household income. Select either option 1 for credit report authorization or option 2 to provide proof of income with documentation.
4. In Section 3, confirm the applicant declarations and authorizations. Ensure this section is signed and dated, affirming that all provided information is accurate.
5. Complete Section 4, where a physician or prescriber must fill in the prescription details. They should list the prescribed Merck product(s) with corresponding strength, quantity, and directions for use.
6. The final section, Section 5, must be filled in by your physician or prescriber. They will provide their details, sign, and date the application. Remember that original signatures are required.
7. Once all sections are completed and signed, mail your application to Merck Patient Assistance Program, PO Box 690, Horsham, PA 19044, in the enclosed business reply envelope or your own properly addressed envelope.
8. You may either save changes to your document, download a copy for your records, print a hard copy, or share it as needed.

Complete your application online today to take advantage of the Merck Patient Assistance Program.