FORMS & DOCUMENTS

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Electronic enrollment
The Merck Access Program Electronic Enrollment Form This form can be signed and submitted electronically. Use this form only if the patient is in the office and you are able to complete the form together.

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The Merck Access Program Electronic Health Care Provider Enrollment Form This Health Care Provider form can be signed and submitted electronically. Please note that the patient must also submit the Electronic Patient Enrollment Form, which can be found at www.merckaccessprogram-zinplava.com/hcc.

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Enrollment
The Merck Access Program Enrollment Form

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Available Independent Foundation Support
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Representative’s Form
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Coding and billing resources
Billing and Coding Guide
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Sample CMS-1500 Form
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Sample UB-04 Form
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Coverage and reimbursement information
Prior Authorization Checklist
Sample Prior Authorization Letter
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Appeal Checklist
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Sample Appeal Letter
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Product information
List of Authorized Distributors
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Physician Prescribing Information
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Patient Information
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The information available here is compiled from sources believed to be accurate, but Merck makes no representation that it is accurate. This information is subject to change. Payer coding requirements may vary or change over time, so it is important to regularly check with each payer as to payer-specific requirements.
The information available here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Merck and its agents make no warranties or guarantees, express or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs.
You are solely responsible for determining the appropriate codes and for any action you take in billing. Information about HCPCS codes is based on guidance issued by the Centers for Medicare & Medicaid Services applicable to Medicare Part B and may not apply to other public or private payers. Consult the relevant manual and/or other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes. Diagnosis codes should be selected only by a health care professional.

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