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for our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK PROGRAMS TO HELP THOSE IN NEED BELSOMRA ® (suvorexant) C-IV . CANCIDAS ® (caspofungin acetate) for Injection . CUBICIN ® (daptomycin for injection), for Intravenous Use . DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID ® (fidaxomicin) for oralsuspension 40 mg/mL
MERCK PROGRAMS TO HELP THOSE IN NEED The Merck Patient Assistance Program, Inc., may be able to provide medicines and adult vaccines free of charge through periodic bulk replenishments to eligible facilities that serve a large percentage of low-income, uninsured patients. MERCK PROGRAMS TO HELP THOSE IN NEED RENFLEXIS™ (infliximab-abda) for injection, for intravenous use* This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED If you have any general questions about the Merck Patient Assistance Program, please call 1-800-727-5400, Monday through Friday, 8 AM to 8PM ET.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
ENTER A PARTICIPATING MERCK PRODUCT TO LEARN MORE Enter a participating Merck product to learn more Enter a participating Merck product to learn more MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. APPLICANT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL sign sign this is the prescription. please do not submit a prescription separate from this application.* patient’s first namem.i. last name
MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK PROGRAMS TO HELP THOSE IN NEED The Merck Patient Assistance Program, Inc., may be able to provide medicines and adult vaccines free of charge through periodic bulk replenishments to eligible facilities that serve a large percentage of low-income, uninsured patients. MERCK PROGRAMS TO HELP THOSE IN NEED BELSOMRA ® (suvorexant) C-IV . CANCIDAS ® (caspofungin acetate) for Injection . CUBICIN ® (daptomycin for injection), for Intravenous Use . DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID ® (fidaxomicin) for oralsuspension 40 mg/mL
MERCK PROGRAMS TO HELP THOSE IN NEED If you have any general questions about the Merck Patient Assistance Program, please call 1-800-727-5400, Monday through Friday, 8 AM to 8PM ET.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. APPLICANT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL merck patient assistance program enrollment form patient must complete this side. section 1: complete the patient information below. please print in legible capital letters PROGRAMAS DE ASISTENCIA PARA PACIENTES DE MERCK …TRANSLATE THIS PAGE En Merck creemos que nadie debe quedarse sin las medicinas o las vacunas que necesita. Es por ello que la compañía proporciona cierta medicación y vacunas para adultos de manera gratuita a las personas que no tienen cobertura para medicamentos recetados o de seguro médico y que, sin nuestra ayuda, no podrían pagar la medicación ni las vacunas de Merck. PROGRAMAS DE MERCK PARA AYUDAR A QUIENES LO …TRANSLATE THIS PAGE RENFLEXIS™ (infliximab-abda) for injection, for intravenous use* Este programa privado y confidencial proporciona productos gratuitos a personas elegibles, principalmente a aquellas sin cobertura de seguro, quienes, sin nuestra asistencia, no podrían afrontar el gasto quesupone la
MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. MERCK PROGRAMS TO HELP THOSE IN NEED BELSOMRA ® (suvorexant) C-IV . CANCIDAS ® (caspofungin acetate) for Injection . CUBICIN ® (daptomycin for injection), for Intravenous Use . DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID ® (fidaxomicin) for oralsuspension 40 mg/mL
MERCK PROGRAMS TO HELP THOSE IN NEED The Merck Patient Assistance Program, Inc., may be able to provide medicines and adult vaccines free of charge through periodic bulk replenishments to eligible facilities that serve a large percentage of low-income, uninsured patients. MERCK PROGRAMS TO HELP THOSE IN NEED If you have any general questions about the Merck Patient Assistance Program, please call 1-800-727-5400, Monday through Friday, 8 AM to 8PM ET.
MERCK PROGRAMS TO HELP THOSE IN NEED ONTRUZANT ® (trastuzumab-dttb) for injection, for intravenous use This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. APPLICANT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL merck patient assistance program enrollment form patient must complete this side. section 1: complete the patient information below. please print in legible capital letters MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. MERCK PROGRAMS TO HELP THOSE IN NEED BELSOMRA ® (suvorexant) C-IV . CANCIDAS ® (caspofungin acetate) for Injection . CUBICIN ® (daptomycin for injection), for Intravenous Use . DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID ® (fidaxomicin) for oralsuspension 40 mg/mL
MERCK PROGRAMS TO HELP THOSE IN NEED The Merck Patient Assistance Program, Inc., may be able to provide medicines and adult vaccines free of charge through periodic bulk replenishments to eligible facilities that serve a large percentage of low-income, uninsured patients. MERCK PROGRAMS TO HELP THOSE IN NEED If you have any general questions about the Merck Patient Assistance Program, please call 1-800-727-5400, Monday through Friday, 8 AM to 8PM ET.
MERCK PROGRAMS TO HELP THOSE IN NEED ONTRUZANT ® (trastuzumab-dttb) for injection, for intravenous use This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. APPLICANT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL merck patient assistance program enrollment form patient must complete this side. section 1: complete the patient information below. please print in legible capital letters MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED Note: During this unprecedented time, if you have lost your job and health insurance due to the COVID-19 pandemic and need help paying for your Merck medicines, the Merck Patient Assistance Program may be able to provide your Merck medicines at no cost. MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED RENFLEXIS™ (infliximab-abda) for injection, for intravenous use* This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK PATIENT ASSISTANCE PROGRAMS TO HELP THOSE IN NEED800-727-5400HOMEPROGRAMSPRODUCTSHEALTH CARE PROFESSIONALSFAQS Medicines or adult vaccines distributed through the Merck Patient Assistance Programs are free of charge to all eligible patients. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment formsfor our programs.
MERCK PROGRAMS TO HELP THOSE IN NEED If you believe that you meet the eligibility criteria for the Merck Patient Assistance Program and you have received a prescription for a Merck product, call toll-free 800-727-5400 8 AM to 8 PM ET to obtain a brochure outlining the program and an enrollment application, or by clicking on the link on the right. MERCK PROGRAMS TO HELP THOSE IN NEED Note: During this unprecedented time, if you have lost your job and health insurance due to the COVID-19 pandemic and need help paying for your Merck medicines, the Merck Patient Assistance Program may be able to provide your Merck medicines at no cost. MERCK PROGRAMS TO HELP THOSE IN NEED At Merck, we believe that no one should go without the medicines or vaccines they need. That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our MERCK PROGRAMS TO HELP THOSE IN NEED RENFLEXIS™ (infliximab-abda) for injection, for intravenous use* This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED You may be eligible for the program if all 3 of the following conditions apply: You reside in the United States and are age 19 or older* AND. You have no health insurance coverage (some examples of health insurance coverage include private insurance, HMOs, PPOs, college health plans, Medicaid, veterans' assistance, or any other social service agency support) MERCK PATIENT ASSISTANCE PROGRAM merckhelps.com QUESTIONS? CALL 800-727-5400 Welcome to the Merck Patient Assistance Program Sometimes, affording prescription medicinescan be difficult.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM Patient’s First Name US Resident* Last Name Address Apt. No. City State ZIP Phone Date of Birth Provide an e-mail address if you would like to e notified b MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK PROGRAMS TO HELP THOSE IN NEED BELSOMRA ® (suvorexant) C-IV . CANCIDAS ® (caspofungin acetate) for Injection . CUBICIN ® (daptomycin for injection), for Intravenous Use . DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID ® (fidaxomicin) for oralsuspension 40 mg/mL
MERCK PROGRAMS TO HELP THOSE IN NEED RENFLEXIS™ (infliximab-abda) for injection, for intravenous use* This private and confidential program provides product free of charge to eligible individuals, primarily the uninsured who, without our assistance, could not afford needed Merck medicines. MERCK PROGRAMS TO HELP THOSE IN NEED If you have any general questions about the Merck Patient Assistance Program, please call 1-800-727-5400, Monday through Friday, 8 AM to 8PM ET.
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION CHECKLIST Merck Vaccine Patient Assistance Program Application Checklist At Merck, we believe no one should go without the adult vaccines they need. Adult vaccines distributed MERCK VACCINE PATIENT ASSISTANCE PROGRAM Other Important Information Vaccines distributed through the Merck Vaccine Patient Assistance Program are free of charge to all eligiblepeople.
MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM CHECKLIST Merck Patient Assistance Program Enrollment Form Checklist At Merck, we believe no one should go without the medicines they need. That iswhy the company
MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION Patient name (first, last) Please read the Applicant Authorization and sign the section to indicate your agreement. APPLICANT AUTHORIZATION By signing below, I authorize my health care provider(s) and health plans, including Medicare, to disclose to the MERCK VACCINE PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1: Applicant Information (Patient should complete all information in Section 1.) Patient’s First Name US Resident* Yes No Last Name Address Apt. No. APPLICANT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL merck patient assistance program enrollment form patient must complete this side. section 1: complete the patient information below. please print in legible capital letters PROGRAMAS DE MERCK PARA AYUDAR A QUIENES LO …TRANSLATE THIS PAGE RENFLEXIS™ (infliximab-abda) for injection, for intravenous use Este programa privado y confidencial proporciona productos gratuitos a personas elegibles, principalmente a aquellas sin cobertura de seguro, quienes, sin nuestra asistencia, no podrían afrontar el gasto quesupone la
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OUR PROGRAMS ARE FREE OF CHARGE TO ALL ELIGIBLE PATIENTS __ VIEW OUR PROGRAMS FREQUENTLY ASKED QUESTIONS__ CLICK HERE
MERCK PATIENT ASSISTANCE PROGRAM BROCHURE __ CLICK HERE TO VIEW MERCK VACCINE PATIENT ASSISTANCE PROGRAM BROCHURE __ CLICK HERE TO VIEW HOW TO FILL OUT THE MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM. __ CLICK HERE TO VIEW THE VIDEO __ DOWNLOAD A CHECKLIST HOW TO FILL OUT THE MERCK VACCINES PATIENT ASSISTANCE PROGRAMENROLLMENT FORM.
__ CLICK HERE TO VIEW THE VIDEO __ DOWNLOAD A CHECKLIST THE MERCK PATIENT ASSISTANCE PROGRAM HELPS THOSE IN NEED__
AT MERCK, WE BELIEVE THAT NO ONE SHOULD GO WITHOUT THE MEDICINES ORVACCINES THEY NEED.
That is why the company provides certain medicines and adult vaccines for free to people who do not have prescription drug or health insurance coverage and who, without our assistance, cannot afford their Merck medicine and vaccines. This is consistent with Merck's long-held values and traditions of putting patients first. If you or someone you know needs help paying for medicines or adult vaccines, the Merck Patient Assistance Program, Inc., may be able tohelp.
Merck is a proud participant in the MEDICINE ASSISTANCE TOOL. Visit MEDICINEASSISTANCETOOL.ORG MEDICINES OR ADULT VACCINES DISTRIBUTED THROUGH THE MERCK PATIENT ASSISTANCE PROGRAMS ARE FREE OF CHARGE TO ALL ELIGIBLE PATIENTS. Merck is not associated with any individuals or organizations that may charge patients a fee to assist them in completing enrollment forms for our programs. These individuals or organizations are acting independently of Merck, and do not have Merck's consent. These programs are not insurance. All of the photos depicted on this web site are models and are being used for illustrative purposes only. SELECT A PARTICIPATING MERCK PRODUCT FROM THE LIST BELOW* ALL
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BELSOMRA® (suvorexant) C-IV CANCIDAS® (caspofungin acetate) for Injection CUBICIN® (daptomycin for injection), for IntravenousUse
DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID® (fidaxomicin) for oral suspension40 mg/mL
DIFICID® (fidaxomicin) tablets EMEND® (aprepitant) for OralSuspension 125 mg
EMEND® (aprepitant) 80 mg, 125 mg capsules EMEND® (fosaprepitant dimeglumine) forInjection 150 mg
GARDASIL®9 (Human Papillomavirus 9-valent Vaccine,Recombinant)
ISENTRESS® (raltegravir) 400 mg film-coated and 25 mg and 100 mg chewable Tablets ISENTRESS® HD (raltegravir) 600 mg Tablets ISENTRESS® OS (raltegravir) 100 mg Granules forSuspension
JANUMET® (sitagliptin and metformin HCI) Tablets JANUMET® XR (sitagliptin and metformin HCI extended-release) Tablets JANUVIA® (sitagliptin) Tablets KEYTRUDA® (pembrolizumab) Injection 100 mg M-M-R® II (Measles, Mumps, and Rubella VirusVaccine Live)
NOXAFIL® (posaconazole) oral suspension, 40 mg/mL NOXAFIL® (posaconazole) delayed-releasetablets 100 mg
ONTRUZANT® (trastuzumab-dttb) for injection, forintravenous use*
PIFELTRO™ (doravirine) tablets, for oral use PNEUMOVAX®23 (Pneumococcal Vaccine Polyvalent) PREVYMIS™ (letermovir) 240 mg Tablets PROVENTIL® HFA (albuterol sulfate) InhalationAerosol
RECARBRIO™ (imipenem, cilastatin, and relebactam) for injection, for intravenous useRECOMBIVAX HB®
RENFLEXIS™ (infliximab-abda) for injection, forintravenous use*
STROMECTOL® (ivermectin) Tablets TRUSOPT® (dorzolamide hydrochloride ophthalmic solution)2%
VAQTA® (Hepatitis A Vaccine, Inactivated) VARIVAX® (Varicella Virus Vaccine Live) VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs ZEPATIER® (elbasvir and grazoprevir) ZERBAXA™ (ceftolozane and tazobactam) for Injection forIntravenous Use
ZINPLAVA™ (bezlotoxumab) Injection 25 mg/ml ZOLINZA® (vorinostat) 100 mg Capsules *Merck Patient Assistance Program, Inc., operating on behalf of Organon Patient Assistance Program BELSOMRA® (suvorexant) C-IV CANCIDAS® (caspofungin acetate) for Injection CUBICIN® (daptomycin for injection), for IntravenousUse
DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use DIFICID® (fidaxomicin) for oralsuspension 40 mg/mL
DIFICID® (fidaxomicin) tablets EMEND® (aprepitant) 80 mg, 125 mg capsules EMEND® (fosaprepitant dimeglumine) forInjection 150 mg
EMEND® (aprepitant) for OralSuspension 125 mg
GARDASIL®9 (Human Papillomavirus 9-valent Vaccine,Recombinant)
ISENTRESS® (raltegravir) 400 mg film-coated and 25 mg and 100 mg chewable Tablets ISENTRESS® HD (raltegravir) 600 mg Tablets ISENTRESS® OS (raltegravir) 100 mg Granules forSuspension
JANUMET® (sitagliptin and metformin HCI) Tablets JANUMET® XR (sitagliptin and metformin HCI extended-release) Tablets JANUVIA® (sitagliptin) Tablets KEYTRUDA® (pembrolizumab) Injection 100 mg M-M-R® II (Measles, Mumps, and Rubella VirusVaccine Live)
NOXAFIL® (posaconazole) oral suspension, 40 mg/mL NOXAFIL® (posaconazole) delayed-releasetablets 100 mg
ONTRUZANT® (trastuzumab-dttb) for injection, forintravenous use*
PIFELTRO™ (doravirine) tablets, for oral use PNEUMOVAX®23 (Pneumococcal Vaccine Polyvalent) PREVYMIS™ (letermovir) 240 mg Tablets PROVENTIL® HFA (albuterol sulfate) InhalationAerosol
*Merck Patient Assistance Program, Inc., operating on behalf of Organon Patient Assistance Program RECARBRIO™ (imipenem, cilastatin, and relebactam) for injection, for intravenous useRECOMBIVAX HB®
RENFLEXIS™ (infliximab-abda) for injection, forintravenous use*
STROMECTOL® (ivermectin) Tablets TRUSOPT® (dorzolamide hydrochloride ophthalmic solution)2%
VAQTA® (Hepatitis A Vaccine, Inactivated) VARIVAX® (Varicella Virus Vaccine Live) VERQUVO™ (vericiguat) 2.5mg tabs / 5mg tabs /10mg tabs ZEPATIER® (elbasvir and grazoprevir) ZERBAXA™ (ceftolozane and tazobactam) for Injection forIntravenous Use
ZINPLAVA™ (bezlotoxumab) Injection 25 mg/ml ZOLINZA® (vorinostat) 100 mg Capsules *Merck Patient Assistance Program, Inc., operating on behalf of Organon Patient Assistance Program Copyright © 2021 Merck Sharp & Dohme Corp., a subsidiary of MERCK & CO., INC. All rights reserved.US-NON-06064 08/20
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