Merck Patient Assistance Form – Fill Out and Use This PDF

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.

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

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

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

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.

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.