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The Merck Access Program Enrollment Form

1/17 The Merck Access Program Enrollment FormPhone: 855-257-3932, Fax: 855-755-0518 The Merck Access ProgramPO Box 29067 Phoenix, AZ 85038To geT sTarTed, compleTe The Enrollment form and fax iT To 855-755-0518. please check The box nexT To The producT prescribedEMEND (aprepitant) capsules 125/80 mg, for oral useEMEND (fosaprepitant dimeglumine) for Injection 150 mg, for intravenous useINTRON A (interferon alfa-2b, recombinant) for Injection, 10 million IU, 18 million IU, 50 million IUPlease read the Medication Guide and Instructions for Use for Powder for Solution and Solution for Injection for INTRON A, including the information that INTRON A can cause serious side effects that may cause death or may worsen certain serious diseases that you may already have. Please discuss this information with your doctor. The physician Prescribing Information also is (peginterferon alfa-2b) for injection 200 mcg, 300 mcg, 600 mcg, for subcutaneous usePlease read the Medication Guide and Instructions for Use for SYLATRON, including the information that SYLATRON can cause serious mental health problems which can lead to suicide, and discuss it with your doctor.

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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The Merck Access Program Enrollment Form

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1/6 The Merck Access Program Enrollment Form TO GET STARTED, COMPLETE THE ENROLLMENT FORM AND FAX IT TO 855-755 …

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