Transcription of MERCK VACCINE PATIENT ASSISTANCE PROGRAM …
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MERCK VACCINE PATIENT ASSISTANCE PROGRAM …
SECTION 1: Applicant Information ( PATIENT should complete all information in Section 1.) PATIENT s First NameUS Resident* Yes NoLast NameAddressApt. No. CityStateZIP PhoneDate of BirthGender Male FemaleDo you have Medicare insurance? Ye s NoMedicare beneficiaries only:Do you have Medicare Part D? Ye s NoDo you have any other health insurance coverage of any kind (public or private)? Ye s NoExamples:Medicaid, veterans benefits, health maintenance organization (HMO), preferred provider organization (PPO), college health plan, federal or state insurance, or health ASSISTANCE programAre you covered under another individual s health insurance plan?
SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No.
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