ENROLL NOW

Please click on the links below to access The Merck Access Program forms that are applicable to you. If your patient is requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription for ZINPLAVA. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.

DOWNLOAD & PRINT

This form can be downloaded and printed, and requires an original signature.

Enrollment Form

NEW SIGN & SUBMIT ELECTRONICALLY

These forms can be signed and submitted electronically.

PATIENT IN OFFICE

Electronic Enrollment Form

Use this form if the patient is in the office and you are able to complete the form together.

PATIENT NOT IN OFFICE

Electronic Health Care Provider Enrollment Form

Use this form when the patient is not in the office to complete the form with you.

The patient must also submit the Electronic Patient Enrollment Form.

 

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