Please click on the links below to access The Merck Access Program forms that are applicable to you. If your patient is requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription 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.
SIGN & SUBMIT ELECTRONICALLY
These forms can be signed and submitted electronically.
PATIENT IN OFFICE
Electronic Enrollment Form
Use this form if the patient is in the office and you are able to complete the form together.
PATIENT NOT IN OFFICE
Electronic Health Care Provider Enrollment Form
Use this form when the patient is not in the office to complete the form with you.
The patient must also submit the
Electronic Patient Enrollment Form.