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Merck Patient Assistance Program
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MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT …
merckhelps.comform. I understand that assistance received through the Merck PAP is not insurance. M M D D Y Y Y Y Send completed and SIGNED forms to: Merck Patient Assistance Program, PO Box 690, Horsham, PA 19044-9979 For inquiries, please call 800-727-5400 Use a Black or Blue Pen 1-800-727-5400 Physician must complete Sections 2 and 3 on next page ...
TO GET STARTED, COMPLETE THE ENROLLMENT FORM AND …
harbourwomenshealth.comPATIENT AUTHORIZATION (REQUIRED if “Prescription Order” has been requested above) I understand that in order for Merck Sharp & Dohme B.V., a subsidiary of Merck & Co., Inc., and Lash (the company that will conduct reimbursement support on behalf of Merck) to provide me with assistance, Lash and