Merck Patient Assistance Program Application
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3Important Steps for Patient and Physician/Prescriber:
1. Complete ALL information on the application form.
You may fill in the fields online and print it.
OR
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
application.
• 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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Parent category: Medical