Merck Patient Assistance Form PDF Details

Accessing essential medications can be a financial struggle for many individuals, making the role of patient assistance programs pivotal in bridging this gap. The Merck Patient Assistance Program (PAP) embodies this support, offering eligible patients access to their medications at no cost. Through the convenient process of the Merck Patient Assistance Enrollment Form, patients provide crucial information needed for program eligibility evaluation. This detailed form requires patients to fill out personal information, including residency status, household income, and current prescription coverage, using a black or blue pen to ensure clarity. Additionally, it requests verification of the patient's inability to afford the medication, alongside a declaration not to seek reimbursement for provided medication through other insurers or government programs. Physicians play a crucial role, completing a section of the form to include prescription details and medical supervision attestation. The form also comprises patient authorizations concerning the use and disclosure of personal health information necessary for program assistance. This comprehensive approach underscores the program's commitment to facilitating access to medications, emphasizing the need for accurate and honest communication from all parties involved. Aspiring participants are reminded of the importance of completeness and accuracy in their application, pivotal in determining their qualification for the program.

QuestionAnswer
Form NameMerck Patient Assistance Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmerck patient assistance, merck patient assistance program, merck patient assistance application pdf, merck patient assistance program application

Form Preview Example

PO Box 690 Horsham, PA 19044-9979

MERCK PATIENT ASSISTANCE PROGRAM

ENROLLMENT FORM

For inquiries, please call 800-727-5400

PATIENT MUST COMPLETE THIS SIDE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Use a Black or

SECTION 1: COMPLETE THE PATIENT INFORMATION BELOW. PLEASE PRINT IN LEGIBLE CAPITAL LETTERS

Blue Pen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes No

Patient’s First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M.I.

 

US Resident*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

City

Phone

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M M D D

Provide an e-mail address if you would like to be notified with an acknowledgement of enrollment form receipt

State

Y Y Y Y

Apt. No.

ZIP

Gender: Male

 

Female

 

 

 

List current annual gross household income below. Indicate the source(s) of your income by checking all boxes that apply.

Total Annual Income

$

 

 

 

 

 

 

 

 

 

No. of Household

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Members

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(including patient)

 

Social Security Benefits (SS, SSI, SSDI)

 

Wages

 

Interest/Dividends

 

 

 

Pension

 

Unemployment Compensation

 

Please list other income source(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I would like my product shipped to: My Home

 

 

 

My Physician’s Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have prescription coverage? Yes No

If yes, please check all boxes that apply.

Medicare

 

Medicaid

State Pharmacy

Employer

Medicare Part D

Private Policy

Other (e.g. Medicare Supplement)

 

If other, please complete

 

 

 

 

Insurance Carrier

 

 

 

Phone No.

 

Policy ID

 

 

 

Group No.

 

 

 

 

 

 

 

Applicant Declarations and Authorization

I certify that all of the information provided in this application, including household income, is complete and accurate. I understand that program assistance will terminate if the program becomes aware of any fraud or if this medication is no longer prescribed for me. I understand that completing this application does not ensure that I will qualify for this program. I certify that I cannot afford this medication. I certify that I will not seek reimbursement or credit for this prescription from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I will not seek to have this prescription or any cost associated with it counted as part of my out-of-pocket cost for prescription drugs.

I understand that Merck PAP reserves the right to modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice. I authorize Merck PAP and its affiliates to forward this prescription to a dispensing pharmacy on my behalf. Merck PAP is not acting as a dispensing pharmacy. Merck PAP is not responsible for verifying any information contained in Section 2, including without limitation allergies, medical conditions, or other medications being taken by me. With respect to this application, I understand that only the dispensing pharmacy will be responsible for the information contained in Section 2 of this application form.

SIGN

Patient’s Original Signature _________________________ Date

 

 

M M D D Y Y Y Y

Applicant Authorization for Use and Disclosure of Personal Health Information

I understand that in order for the Merck Patient Assistance Program, Inc. (Merck PAP) to provide me with assistance, it will need to obtain, review, use, and disclose my personal health information (PHI), including information relating to my medical condition and information on my application form. I agree to allow the Merck PAP Program to contact me via mail, telephone or email to carry out these services. I authorize my physician, pharmacy, and my health plan(s) to disclose my PHI to Merck PAP and its administrators as necessary to complete the Merck PAP application process or to verify my application. I understand that my name, address, and any other personal identifying information provided in my application will be available to Merck PAP and its affiliates. I understand that my PHI disclosed under this application may no longer be protected by privacy laws and may be re-disclosed by Merck PAP only for the purposes described here. I understand that I if I don’t provide this Authorization, I won’t be able to obtain assistance from Merck PAP. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician and Merck PAP, and the cancellation will not apply to any information already used or disclosed pursuant to this Authorization. If I do not cancel this Authorization, the Authorization will expire 15 months from the date signed below. I also understand that information concerning program participants may be summarized for statistical or other purposes and provided to Merck PAP, but that any such summary shall be of de-identified data and shall not disclose, nor be able to be used to disclose, my identity. I have read this document or have had it explained to me. I understand that I may request a copy of this Authorization once it

has been signed.

SIGN Patient’s Original Signature _________________________ Date

M M D D Y Y Y Y

*You do not have to be a US citizen.

Physician must complete Sections 2 and 3 on the back of this form.

Merckhelps.com

PHYSICIAN/PRESCRIBER MUST COMPLETE THIS SIDE.

SECTION 2: COMPLETE THE PRESCRIPTION AND PRODUCT INFORMATION BELOW. PLEASE PRINT IN LEGIBLE CAPITAL LETTERS

THIS IS THE PRESCRIPTION. PLEASE DO NOT SUBMIT A PRESCRIPTION SEPARATE FROM THIS APPLICATION.

Use a Black or Blue Pen

Patient’s First Name

Last Name

Date of Birth

M M D D Y Y Y Y

M.I.

Product Name

 

Strength

 

Quantity

 

Directions

 

Refill

 

(1, 2, or 3) Times

Product Name

 

 

Strength

 

 

Quantity

 

 

Directions

 

Refill

 

(1, 2, or 3) Times

Product Name

 

 

Strength

 

 

Quantity

 

 

Directions

 

Refill

 

(1, 2, or 3) Times

Physician/Prescriber State License Number

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN

Dispense As Written: Physician/Prescriber’s Signature _______________________________ (We cannot accept signature stamps)

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES:

None

Aspirin

 

Codeine

Iodine

 

Penicillin

Sulfa

Other __________________________________

MEDICAL CONDITIONS:

None

Asthma

Glaucoma

Heart

High BP

Ulcer

Other __________________________________

CURRENT MEDICATION(S) BEING TAKEN BY THE PATIENT:________________________________________________________________________

SECTION 3: PHYSICIAN/PRESCRIBER MUST COMPLETE, SIGN AND DATE.

Physician’s First Name

Physician’s Last Name

Professional Designation

Name of Facililty/Site

Mailing Address (PO Boxes not permitted)

Street Address 1

Street Address 2

City

M.I.

State ZIP

Office Phone

Secure Fax

-

-

-

-

Ext.

Office Contact Name ____________________________________ E-mail Address _________________________________________________

Physician/Prescriber Attestation

I certify that this prescription is medically appropriate for this patient and that I will be supervising the patient’s treatments. I verify that the information provided is complete and accurate to the best of my knowledge. I authorize the Merck PAP, its affiliated companies, or its subcontractors to forward this prescription to a dispensing pharmacy on behalf of myself and my patient. I understand that Merck PAP reserves the right to modify or discontinue this program at this facility/practice, or terminate assistance at any time and without notice.

SIGN

Physician’s/Prescriber’s Original Signature _____________________________________

Date

M M D D Y Y Y Y

This form should not be tampered with or revised in anyway. Only originals with ink signatures will be accepted.

To report an adverse event to a specific Merck product, including death due to any cause, please contact the Merck National Service Center at 1-800-444-2080.

CORP-1083762-0001 10/13

Tear here, place enrollment form in envelope, and mail.

Merckhelps.com

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Writing segment 1 in merck patient assistance form 2021

2. Once your current task is complete, take the next step – fill out all of these fields - Applicant Declarations and, SIGN, Patients Original Signature Date, M M, Applicant Authorization for Use, SIGN, Patients Original Signature Date, M M, You do not have to be a US citizen, Physician must complete Sections, and Merckhelpscom with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Ways to complete merck patient assistance form 2021 part 2

3. Completing THIS IS THE PRESCRIPTION PLEASE DO, Patients First Name, Last Name, Date of Birth, Product Name, Product Name, Product Name, M M, Strength, Quantity, Directions, Refill, or Times, Strength, and Quantity is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Ways to prepare merck patient assistance form 2021 portion 3

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4. Now fill out this next segment! In this case you will get all of these SECTION PHYSICIANPRESCRIBER MUST, Physicians First Name, Physicians Last Name, Professional Designation, Name of FacililtySite, Mailing Address PO Boxes not, Street Address, Street Address, City, Office Phone, Secure Fax, Ext, State, ZIP, and Office Contact Name Email Address blanks to fill in.

merck patient assistance form 2021 conclusion process shown (portion 4)

5. Because you come close to the finalization of your file, there are a few more requirements that need to be satisfied. Mainly, SIGN, PhysiciansPrescribers Original, Date, M M, This form should not be tampered, To report an adverse event to a, CORP, Tear here place enrollment form in, and Merckhelpscom must all be filled out.

Filling out segment 5 in merck patient assistance form 2021

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