Merck Patient Assistance Program Application

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Important Steps for Patient and Physician/Prescriber:
1. Complete ALL information on the application form.
You may fill in the fields online and print it.
You may print out the form and fill it out by hand using a black ballpoint pen.
2. Take the completed application to your physician/prescriber. Both the physician/
prescriber and the patient MUST sign the application.
3. Have your physician/prescriber write your prescription(s) in Section 2 of the
• A single application may include prescriptions for up to 3 Merck medicines.
• Each prescription may not exceed a 90-day supply at a time, with a maximum
of 3 refills.
• Each application is valid for up to 12 months; after 12 months a new
application will be required. Under certain circumstances, enrollment may be limited
to a calendar year.
• A separate Merck Patient Assistance Program application is REQUIRED for
each patient.
4. Mail completed applications to:
Merck Patient Assistance Program
PO Box 690
Horsham, PA 19044-9979
Please Note:
• Incomplete or incorrectly completed applications will be returned.
• Section 2 is your prescription. There is no need to write your prescription
on a separate prescription form.
• Patient’s prescription will be sent to the patient’s home address unless
otherwise requested by the patient/prescriber in Section 1 of the application.
• For additional applications or assistance, please call 1-800-727-5400.


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