To get started, select a category above or call 855-404-5278 to speak with a representative, Monday through Friday, 8AM to 8PM ET
To get started, select a category above or call 855-404-5278 to speak with a representative, Monday through Friday, 8 AM to 8 PM ET
THE MERCK ACCESS PROGRAM
THE MERCK ACCESS PROGRAM
CAN HELP ANSWER QUESTIONS ABOUT:
Use this link to securely upload documents to submit to The Merck Access Program
REMEMBER TO: 
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Download and print the enrollment form |
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Complete and sign the patient sections of the enrollment form (pages 1-4) |
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Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6) |
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Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127 |
REMEMBER TO:
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Download and print the enrollment form |
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Complete and sign the patient sections of the enrollment form (pages 1-4) |
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Make sure your healthcare provider reads and signs the healthcare provider section of the enrollment form (pages 5-6) |
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Fax or ask your healthcare provider to help you fax your enrollment form to 866-866-4127 |
REMEMBER TO:
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Use this option to complete the enrollment form electronically |
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Make sure you talk to your healthcare provider if you have any questions or concerns |
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Fill out your name and the date when asked on the form |
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Complete and sign all relevant sections of the enrollment form |
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Submit the form electronically |
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Ask your healthcare provider to complete and submit the Healthcare Provider Enrollment Form |
REMEMBER TO:
Sign & Submit Electronically
REMEMBER TO: Sign & Submit Electronically
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Use this option to complete the enrollment form electronically with the patient |
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Fill out and sign the healthcare provider section of the enrollment form |
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Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form |
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Submit the form electronically |
REMEMBER TO:
Download & Print
REMEMBER TO: Download & Print
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Download and print the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
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Include a copy of the front and back of the patient’s insurance card |
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Fax the completed form to 866-866-4127 |
REMEMBER TO:
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Download and print the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
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Include a front and back copy of the patient’s insurance card |
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Fax the completed form to 866-866-4127 |
REMEMBER TO:
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Complete the patient and insurance information (page 1) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 2-3) |
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Submit the form electronically |
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Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-prevymis.com/hcc |
