ENROLLMENT FORM - The Merck Access Program for KEYTRUDA

The Merck Access Program
ENROLLMENT FORM
Phone: 855-257-3932, Fax: 855-755-0518, TTY: 855-257-7332 • The Merck Access Program, PO Box 29067, Phoenix, AZ 85038
TO GET STARTED, COMPLETE THE ENROLLMENT FORM AND FAX IT TO 855-755-0518. IF REQUESTING A
REFERRAL TO THE MERCK PATIENT ASSISTANCE PROGRAM, PLEASE INCLUDE A PRESCRIPTION FOR KEYTRUDA.
PLEASE CHECK ALL BOXES THAT APPLY AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM
Patient Benefit Investigation and/or information about the Prior Authorization or Appeals Process............................................... Complete Section 1
Merck Co-pay Assistance Program..........................................................................................................................................Complete Sections 1 and 2
Evaluation of eligibility for the Merck Patient Assistance Programa (offered through the Merck Patient Assistance Program, Inc.)......Complete Sections 1 and 3
P roduct replacement, available from the Merck Patient Assistance Program, may be available to health care providers whose patients do not have insurance or whose insurance
does not cover the product, subject to certain financial, medical, and insurance criteria. The Patient Assistance Product Replacement Form may need to be submitted. Please call
The Merck Access Program for additional information.
SECTION 1
a
PATIENT INFORMATION
If another person will be legally signing on behalf of the patient or if the patient would like to designate a person to act on his or her behalf to verify information
and coordinate provisions of the programs described in this enrollment form, PLEASE INCLUDE A COMPLETED REPRESENTATIVE’S FORM WITH THIS
ENROLLMENT FORM.
Patient name:
Address:
(Street address only, no PO boxes)
Date of birth
Sex: M
F
City/State/ZIP:
Phone (home):
(work):
(other):
FOR MERCK PATIENT ASSISTANCE PROGRAM AND MERCK CO-PAY ASSISTANCE PROGRAMS ONLY
Current annual gross household income: $
(Please include: before-tax wages, pension, interest/dividends, Social Security benefits, and any other sources of income.)
Number of household members (including patient):
INSURANCE INFORMATION
PLEASE COMPLETE ALL THAT APPLY AND INCLUDE A FRONT AND BACK COPY OF INSURANCE CARD FOR EACH TYPE OF INSURANCE
Patient Has No Insurance
Primary insurer (including Medicaid, Medicare, veterans benefits, and private insurers)
Plan name and state:
Phone number for customer service:
Name of policyholder:
Policyholder date of birth:
Policyholder relation to patient:
Group no.:
Policy ID no.:
Secondary/supplemental insurer
Plan name and state:
Phone number for customer service:
Name of policyholder:
Policyholder date of birth:
Policyholder relation to patient:
Group no.:
Policy ID no.:
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 1 CONTINUED
Patient name:
PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION
(to be completed by patient or legal representative)
I understand that before I may have communications with The Merck Access Program, sponsored by Merck Sharp & Dohme Corp. (“Merck”), a subsidiary of Merck
& Co., Inc., or receive assistance from the Merck Patient Assistance Program (“PAP”), sponsored by the Merck Patient Assistance Program, Inc. (individually, “a
Program”; collectively, “the Programs”), the administrators of the Programs, including their contractors or other representatives, will need to obtain, review, use,
and disclose my personal health information (“PHI”), including information relating to my medical condition and prescription medications and the information
disclosed in this patient enrollment form.
I therefore authorize each of my physicians, pharmacies, and health plans to disclose my PHI, as necessary, to the administrators of the Programs, McKesson for
The Merck Access Program and RxCrossroads for the Merck PAP, and their contractors or representatives, in order to verify my eligibility to enroll in the Programs
and to enroll me in the Programs for which I am eligible.
I also authorize the administrators of the Programs and their contractors or representatives to use my PHI to provide the services described in this enrollment
form, and to disclose my PHI to my physicians and pharmacists as well as to Medicare, my health plans, and their administrators, contractors, or representatives,
in order for them to coordinate my benefits, provide, when applicable, reimbursement support, and investigate my insurance coverage.
I also authorize my PHI to be disclosed to, and used by, Covance Market Access (“Covance”) and its administrators, contractors, representatives, or third-party
service partners to provide reimbursement support and to investigate insurance coverage in connection with The Merck Access Program.
I also authorize the administrators of the Programs and their contractors and representatives to use my PHI to communicate with me by U.S. postal mail,
telephone, or e-mail to carry out the services described in this enrollment form.
I understand that information concerning program participants may be summarized for statistical or other purposes and provided to Merck and/or the Programs.
If I have designated a Personal Representative, I authorize the Programs, their administrators, and their third-party service partners to use my PHI to contact the
person I have designated as my Personal Representative for the purpose of verifying the information I have provided in this form and/or coordinating the provision
of benefits that may be available to me under the Programs and to disclose my PHI, including information provided in this enrollment form, to my Personal
Representative for the purposes described in this paragraph.
I understand that the PHI disclosed pursuant to this authorization, once disclosed, may not be governed by federal privacy law and may be subject to re-disclosure,
but I also understand that the administrators of the Programs and their contractors and other representatives intend to use and disclose my PHI only for the
purposes described in this authorization. I further understand that if I choose not to provide this authorization, it will not affect my eligibility for, or receipt of,
treatment, including Merck products, or health care insurance benefits, but that I will not be able to receive any assistance from the Programs for which I may
be eligible.
I understand that I may cancel this authorization at any time by telephoning The Merck Access Program at (855) 257-3932 or by mailing a written request for
cancellation to The Merck Access Program, PO Box 29067, Phoenix, AZ 85038. I understand that canceling my authorization will mean that my physicians,
pharmacies, and health plans may no longer rely on the authorization to share my PHI with the Programs, and that the Programs, their administrators, and their
contractors and representatives will not be authorized to use or disclose the information pursuant to this authorization after my cancellation is received, but that
any use or disclosure of such information that occurs before my cancellation is received will be unaffected by my cancellation.
I understand that if I do not cancel this authorization, the authorization will expire 15 months from the date noted below. The administrators of the Programs will
retain the information I have submitted in accordance with Merck’s records retention policy.
I understand that I am entitled to receive a copy of this authorization once it has been signed.
I have read this authorization or have had it explained to me.
I would like to learn more about “KEY+YOU” the free Patient Support Program for people taking KEYTRUDA.
If I decide to enroll in the program, I will have the option to access a nurse 24 hours a day, 7 days a week.
I can also receive information and resources to support me in connection with my treatment with KEYTRUDA,
and can choose whether to receive this information by phone, email, or mail.
I understand that my personal information is needed for this program referral. I agree to allow my information
collected as part of The Merck Access Program to be shared with the agents of the KEY+YOU Patient Support
Program and to allow those agents to contact me to discuss the KEY+YOU Program and its services.
I understand that the use and disclosure of my personal information in connection with referral to the
KEY+YOU Program will be limited to the KEY+YOU Program and its agents. I also understand that my request
for referral to the KEY+YOU Program does not in any way affect my enrollment into The Merck Access
Program and does not obligate me to participate in the KEY+YOU Program.
Signature of patient or legal representative: Date:
Name of signing party (please print):
If this form will be signed by a legal representative of the patient, please include a signed “Representative’s Form” with this enrollment form.
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 1 CONTINUED
Patient name:
HEALTH CARE PROVIDER INFORMATION (to be completed by health care provider)
Physician name:
Physician tax ID no.:
Physician NPI no.:
Physician license no.:
Address:
(Street address only, no PO boxes)
City/State/ZIP:
Phone:
Office contact person:
Fax:
Office contact number:
Same as above
Practice/Facility name:
Practice tax ID no.:
Practice NPI no.:
Practice/Facility address:
(Street address only, no PO boxes)
City/State/ZIP:
Please list all applicable diagnosis codes:
Please list primary tumor type:
HEALTH CARE PROVIDER SIGNATURE AND DECLARATION (to be completed by health care provider)
MUST CONTAIN ORIGINAL SIGNATURE
By signing below, I represent and warrant the following:
• This request has been prepared exclusively by the physician or physician office identified in this request (“my Practice”).
•My Practice has obtained written authorization from the patient identified in this request to disclose the patient’s personal health information (PHI), including
information relating to the patient’s medical condition and prescription medications and the information disclosed in this patient enrollment form, as well as the
information included in this request, to The Merck Access Program, sponsored by Merck Sharp & Dohme Corp. (“Merck”), a subsidiary of Merck & Co., Inc., or
the Merck Patient Assistance Program (“PAP”), sponsored by the Merck Patient Assistance Program, Inc. (individually, “a Program”; collectively, “the
Programs”), the administrators of the Programs, McKesson Specialty Arizona, Inc. (“McKesson”) for The Merck Access Program and RxCrossroads for the
Merck PAP, including their contractors or other affiliates, including, for McKesson, Covance Market Access (“Covance”), and for the Programs to use and
disclose the information for the purposes of benefits investigation and reimbursement support.
•My Practice has provided the patient identified in this request with the notices necessary to comply with all federal and state laws and regulations relating to
medical and/or health privacy, including, but not limited to, the HIPAA Privacy Rule, codified at 45 C.F.R. Parts 160 and 164, as amended from time to time.
•I certify that I, or a physician in my Practice, have determined that the prescribed product is medically appropriate for the patient identified above and that I, or
a physician in my Practice, will be supervising the patient’s treatment.
•If the patient receives product through the Merck PAP, reimbursement for such product administered to the patient will not be sought from any source.
•I also understand that neither I nor my Practice will receive any reimbursement from Merck, whether for administration fees or otherwise.
•I understand that information concerning program participants may be summarized for statistical or other purposes and provided to Merck and/or the Programs.
•I understand that the Program reserves the right to conduct periodic audits of my Practice’s records to verify the information provided herein, excluding
patient-identifiable data (unless the auditor enters into an appropriate agreement with the Practice to protect an individual’s medical privacy).
•I verify that the information provided is complete and accurate to the best of my knowledge.
Physician’s original signature:
Date:
Physician’s name (please print):
To report an adverse event to a specific Merck product, including death due to any cause, please contact the Merck National Service Center
at 800-444-2080.
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 2
Patient name:
THE MERCK CO-PAY ASSISTANCE PROGRAM TERMS AND CONDITIONS
(to be completed by patient or legal representative)
To receive benefits under the Co-pay Assistance Program, the patient must enroll in the Co-pay Assistance Program and be accepted as eligible. Patient may
contact The Merck Access Program for current Program Product(s) subject to these Terms and Conditions.
• Patient must be prescribed the Program Product for an FDA-approved indication.
•Patient must be 18 years of age or older and must have private health insurance that provides coverage for the cost of the Program Product under a medical
benefit plan.
•T he Co-pay Assistance Program is not valid for patients covered under Medicaid (including Medicaid patients enrolled in a qualified health
plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), Medicare,
a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico
Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or
pharmaceutical assistance program (collectively, “Government Programs”). The Co-pay Assistance Program is not valid for uninsured patients.
•Patient must have an out-of-pocket cost for the Program Product and be administered the Program Product prior to the expiration date of the Co-pay Assistance
Program. The benefit available under the Co-pay Assistance Program is valid for the patient’s out-of-pocket cost for the Program Product only. It is not valid for any
other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of the
Program Product. Claim for Program Product must be submitted by physician to patient’s private health insurance separately from other services and products.
• Patient must pay the first $25 of co-pay per administration of Program Product. The benefit available under the Co-pay Assistance Program is limited to
the amount the patient’s private health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for the Program
Product, less $25, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is
$25,000 for patients with an Annual Gross Household Income of less than or equal to 700% of the current Federal Poverty Level, and $10,000 for patients with an
Annual Gross Household Income of more than 700% of the current Federal Poverty Level.
•An EOB from patient’s private health insurance must be submitted within 180 days of the date of the EOB for patient to receive co-pay assistance benefit;
provided, however, that no EOB may be submitted more than 180 days after the expiration date of Co-pay Assistance Program. The EOB must reflect the
patient’s out-of-pocket cost for the Program Product and submission of the claim by the patient’s physician for the cost of the Program Product.
•Patient and physician agree not to seek reimbursement for all or any part of the benefit received by the patient through the Co-pay Assistance Program. Patient
and physician are responsible for reporting receipt of Co-pay Assistance Program benefits to any insurer, health plan, or other third party who pays for or
reimburses any part of the medication cost paid for by the Co-pay Assistance Program, as may be required.
•Patient must be a resident of the United States or the Commonwealth of Puerto Rico. Product must originate and be administered to patient in the United
States or the Commonwealth of Puerto Rico.
•The Program may apply to patient out-of-pocket costs incurred for Program Product within 90 days prior to the date patient is enrolled in the Co-pay Assistance
Program, subject to annual Program maximum and these Terms and Conditions. Patient or physician may contact The Merck Access Program for more
information.
•All information applicable to the Co-pay Assistance Program requested on this form must be provided, and all certifications must be signed. Forms that are
modified or do not contain all the necessary information will not be eligible for benefits under the Co-pay Assistance Program.
•No other purchase is necessary.
•T he Co-pay Assistance Program is not insurance.
•The Co-pay Assistance Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced.
•The Co-pay Assistance Program is void where prohibited by law, taxed, or restricted. The Co-pay Assistance Program is not transferable. No substitutions
are permitted.
•The Co-pay Assistance Program benefit cannot be combined with any other Co-pay Assistance Program, free trial, discount, prescription savings card, or other
offer. Benefits are not available through this Co-pay Assistance Program for product purchased by patient at a pharmacy, even if later administered in a
physician office or outpatient institution.
•Merck reserves the right to rescind, revoke, or amend the Co-pay Assistance Program at any time without notice.
•Data related to patient’s receipt of Co-pay Assistance Program benefits may be collected, analyzed, and shared with Merck, for market research and other
purposes related to assessing Co-pay Assistance Programs. Data shared with Merck will be aggregated and de-identified, meaning it will be combined with
data related to other Co-pay Assistance Program redemptions and will not identify patient.
•These Terms and Conditions are valid for Program Product administered between January 1, 2016, and December 31, 2016. Co-pay Assistance for
administration of Program Product between January 1, 2015, and December 31, 2015, is subject to the 2015 Co-pay Assistance Program Terms and Conditions.
Expiration Date: 12/31/2016.
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 2 CONTINUED
Patient name:
PATIENT CERTIFICATION (to be completed by patient or legal representative)
I certify that I have read and understand the Terms and Conditions of the Co-pay Assistance Program. I certify that I meet the eligibility
requirements listed in the Terms and Conditions and that the information I am providing on this form is true and correct.
I certify that I have private insurance and that no part of the costs associated with the Program Product for which I am seeking a
benefit under the Co-pay Assistance Program was or will be covered or reimbursed by a Government Program, as that term is defined
in the Co-pay Assistance Program Terms and Conditions.
I understand that if I begin to have coverage under any Government Program or if my state prohibits the redemption of manufacturer
Co-pay Assistance (coupons) at any time, I will no longer be eligible to receive benefits under the Co-pay Assistance Program. If I am
enrolled in a qualified health plan purchased through a health insurance exchange established by a state government or the federal
government (QHP), I understand that if the federal government or my state government prohibits the redemption of manufacturer Co-pay
Assistance (coupons) by enrollees in QHPs at any time, I will no longer be eligible to receive benefits under the Co-pay Assistance Program.
I certify that my insurance company has not prohibited the redemption of manufacturer Co-pay Assistance (coupons) for the Program
Product and I understand that if at any time my insurance company prohibits the redemption of manufacturer Co-pay Assistance
(coupons) for the Program Product, I will no longer be eligible to receive benefits under the Co-pay Assistance Program.
I understand that I am responsible for reporting receipt of Co-pay Assistance Program benefits to any insurer, health plan, or other third
party who pays for or reimburses any part of the medication cost paid for by the Co-pay Assistance Program, as may be required.
I agree not to seek reimbursement for all or any part of the benefit I receive through the Co-pay Assistance Program. I understand that
my physician/physician’s office will submit a claim to my private insurance company for the Program Product administered to me. I
authorize my physician/physician’s office to submit the Explanation of Benefits received from my private insurance company to the
Co-pay Assistance Program and to receive, on my behalf, any benefit for which I am eligible under the Program. I understand that my
physician/physician’s office will apply any amounts received from the Co-pay Assistance Program toward the satisfaction of my
obligation for the cost of the Program Product only. I understand that I am responsible to pay my physician/physician’s office the
amount I owe per administration of Program Product consistent with the applicable Terms and Conditions of the Co-pay Assistance
Program, and any balance owed to my physician/physician’s office not covered by the Co-pay Assistance Program. I understand that
co-pay assistance for any administration of Program Product to me between January 1, 2015 and December 31, 2015 is subject to the
2015 Co-pay Assistance Program Terms and Conditions.
I understand that any benefit I am eligible for under the Co-pay Assistance Program will be paid directly to my physician/physician’s
office, on my behalf, and not directly to me. If I have already paid my physician/physician’s office for my share of the cost of the Program
Product for which I later receive a benefit through the Co-pay Assistance Program, I will seek the amount, less the amount I owe per
administration, in accordance with the Co-pay Assistance Program Terms and Conditions, back from my physician/physician’s office.
I understand that I am free to switch physicians at any time without affecting my eligibility to receive benefits under the Co-pay Assistance
Program, provided, however, that my new physician must complete the information required on the form, including the physician certification,
before any Co-pay Assistance Program benefit for which I am eligible may be paid to such physician/physician’s office on my behalf.
I will inform the Co-pay Assistance Program immediately in the event I become ineligible to receive benefits under the
Program Terms and Conditions or if my insurance or income changes.
Signature of patient or legal representative:
Date:
Name of signing party (please print):
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 2 CONTINUED
Patient name:
PHYSICIAN CERTIFICATION (to be completed by health care provider)
I, a licensed health care professional, certify that I have prescribed the Program Product to the patient indicated on this form in the exercise of my
independent medical judgment for an FDA-approved indication.
I have read and agree to the Terms and Conditions of the Co-pay Assistance Program. I certify that, to the best of my knowledge, the patient
meets the criteria set forth in the Terms and Conditions, and that the information I am providing on this form is true and correct.
I certify that I/my office will not take into account the fact that the patient may receive a benefit from the Co-pay Assistance Program when
determining the amount of any charge(s) to the patient. I certify that I/my office will not charge the patient any fee to complete this form and I/my
office will not advertise or otherwise use the Co-pay Assistance Program as means of promoting my services or the Program Product.
I certify that the claim I submit/my office submits to the patient’s private health insurer for payment of the Program Product will have the Program
Product listed separately from any claim for medication administration or any other items or services provided to the patient.
I understand that I am/my office is responsible for reporting receipt of Co-pay Assistance Program benefits to any insurer, health plan, or other
third party who pays for or reimburses any part of the medication cost paid for by the Co-pay Assistance Program, as may be required.
I certify that I/my office will not seek reimbursement for all or any part of the benefit received by the patient through the Co-pay Assistance Program.
I understand that the patient’s benefit received under the Co-pay Assistance Program will be paid directly to me/my office by the Co-pay
Assistance Program on behalf of my patient. I/my office will apply any amounts received from the Co-pay Assistance Program to the satisfaction
of the patient’s obligation for the cost of the Program Product only. If I/my office already received payment from the patient for the patient’s share
of the cost of the Program Product for which the patient receives a benefit through the Co-pay Assistance Program, I/my office will refund the
amounts received (minus the patient’s obligation per administration in accordance with the Program Terms and Conditions) back to the patient.
I understand and agree that the certifications I am providing in this Physician Certification apply to the patient indicated on this form and to any
other patient enrolled in the Co-pay Assistance Program who I treat with the Program Product and any claim I submit/my office submits for Co-pay
Assistance Program benefits on the patient’s behalf. I understand that I may be asked to sign a new Physician Certification if the Terms and
Conditions of the Co-pay Assistance Program for the Program Product change.
Physician’s original signature:
Date:
Physician’s name (please print):
SECTION 3
Is physician licensed in Vermont? Yes
No
If yes, provide Vermont license no.:
THE MERCK PATIENT ASSISTANCE PROGRAM (offered through the Merck Patient Assistance Program, Inc.;
to be completed by patient or legal representative)
APPLICANT DECLARATIONS AND AUTHORIZATIONS
I certify that all of the information provided in this application, including information about household income, is complete and accurate.
I understand that Merck PAP assistance will terminate if the Merck PAP 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 patient assistance. 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 the 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 the 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 the prescription forwarded as part of the enrollment process, 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 such information.
I understand that assistance received through the Merck Patient Assistance Program is not insurance.
Signature of patient or legal representative:
Date:
Name of signing party (please print):
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
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SECTION 3 CONTINUED
Patient name:
MERCK PAP—PATIENT ATTESTATION OF FINANCIAL HARDSHIP
The Merck PAP is designed primarily for individuals who do not have prescription drug or health insurance coverage; however, individuals with
insurance coverage may still request assistance if they attest to a financial hardship (i.e., the individual cannot afford the deductible, co-pay,
co-insurance, or other cost sharing requirement of his or her insurance plan). If you would like to request an exception to the Merck PAP’s
insurance criteria, please carefully review the attestations below and sign and date this section.*
*The Merck PAP evaluates all requests for an exception to its insurance criteria based on a financial hardship on a case-by-case basis, and cannot guarantee that an exception will be made.
1. I attest that without enrollment in the Merck Patient Assistance Program, I would not be able to afford my medication due to high medical
expenses and financial hardship.
My financial hardship is due to (please choose all that are applicable)
a deductible amount
a co-pay amount
a co-insurance amount
other
(please specify)
2. I understand that if I have Medicare coverage, my eligibility will automatically expire on December 31 of the current calendar year and it will be
necessary for me to submit a new application before December 31 for program determination of eligibility for the following year. If I fail to
re-enroll before December 31, I understand that I will no longer receive my medication from the Merck Patient Assistance Program.
I have Medicare Part B coverage (please check applicable box) Yes
No
3. I understand that if I have private prescription drug coverage, my eligibility will automatically expire 1 year from my date of enrollment and I
must re-enroll for program determination of eligibility for the following year.
4. I attest that I will notify the Merck Patient Assistance Program immediately if anything changes with my prescription or my insurance coverage.
5. I understand that the Merck Patient Assistance Program reserves the right to request additional documentation from me to support my request
for an exception based on my financial hardship including, for example, documents relating to my income.
I understand it is my responsibility to promptly inform the Program of any information that changes from what is being submitted on this form.
Signature of patient or legal representative:
Date:
Name of signing party (please print):
THE MERCK ACCESS PROGRAM
PHONE: 855-257-3932, FAX: 855-755-0518, TTY: 855-257-7332
Copyright © 2016 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved. ONCO-1165622-0001 05/16
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