MERCK PATIENT ASSISTANCE PROGRAM 2026

1. Click ‘Get Form’ to open the MERCK PATIENT ASSISTANCE PROGRAM enrollment form in the editor.
2. Begin by completing Section 1 with your personal information. Ensure you print in legible capital letters, including your name, address, phone number, and date of birth.
3. Indicate your annual gross household income and check all applicable sources of income. If you have prescription coverage, specify which type by checking the relevant boxes.
4. In the declarations section, read through the statements carefully and provide your original signature along with the date to confirm accuracy.
5. If applicable, complete Sections 2 and 3 with your physician’s details. Ensure they sign where required to validate the prescription.
6. Review all sections for completeness before saving or printing the document for submission.

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