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The Merck Access Program Enrollment Form

1/9 The Merck Access Program Enrollment FormPhone: 855-257-3932, Fax: 855-755-0518 The Merck Access ProgramPO Box 29067 Phoenix, AZ 85038a Product replacement, available from the Merck Patient Assistance Program , may be available to health care providers whose patients do not have insurance or whose insurance does not cover the product, subject to certain financial, medical, and insurance criteria. The Patient Assistance Product Replacement form may need to be submitted. Please call The Merck Access Program for additional information. Please CheCk all boxes that aPPly and ComPlete the aPProPriate seCtion(s) of the formPatient Benefit InvestigationSection 1 Prior AuthorizationSection 1 AppealSection 1 Merck Co-Pay Assistance ProgramSections 1, 2, 3, 4 Referral to the Merck Patient Assistance Programa (offered through the Merck Patient Assistance Program , Inc.)

1/9 The Merck Access Program Enrollment Form Phone: 855-257-3932, Fax: 855-755-0518 The Merck Access Program PO Box 29067 Phoenix, AZ 85038 aProduct replacement, available from the Merck Patient Assistance Program, may be …

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Applicant Authorization for Use and Disclosure of Personal ...

www.merckhelps.com

Patient’s Original Signature _____ Date I understand that in order for the Merck Patient Assistance Program, Inc. (Merck PAP) to provide me with assistance, it will need to obtain, review, use, and disclose my personal health information (PHI), including information relating to my medical condition and information on my application

  Health, Information, Patients, Personal, Personal health information

Applicant Authorization for Use and Disclosure of …

www.merckhelps.com

merck patient assistance program enrollment form patient must complete this side. section 1: complete the patient information below. please print in legible capital letters

  Authorization

MERCK VACCINE PATIENT ASSISTANCE PROGRAM …

www.merckhelps.com

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. City State ZIP Phone Date of Birth Gender Male Female

  Programs, States, Patients, Assistance, Patient assistance program

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servicealberta.ca

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The Merck Access Program Enrollment Form

www.merckaccessprogram.com

1/17 The Merck Access Program Enrollment Form Phone: 855-257-3932, Fax: 855-755-0518 The Merck Access Program PO Box 29067 Phoenix, AZ 85038 To geT sTarTed, compleTe The enrollmenT form and fax iT To 855-755-0518.

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DD Form 2962, Personnel Security System Access …

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