Please click on the links below to access The Merck Access Program forms that are applicable to you. If you are requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription from your health care provider for PREVYMIS. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
DOWNLOAD & PRINT
This form can be downloaded and printed, and requires an original signature. Work with your health care provider to complete the enrollment form.
NEW SIGN & SUBMIT ELECTRONICALLY
This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the
Health Care Provider Enrollment Form.
Electronic Patient Enrollment Form