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Please utilize the updated MAP Enrollment Form to re-enroll your patients: Complete the new Healthcare Provider Enrollment Form for each patient who requires re-enrollment. You may submit the application online, or print and fax the completed forms; Ensure the patient also completes the Patient Enrollment Form
Download and print the enrollment form; Make sure you talk to your healthcare provider if you have any questions or concerns; Fill out your name and the date when asked on the form; Complete and sign all relevant sections of the enrollment form; Fax or ask your healthcare provider to help you fax your enrollment form to 855-755-0518
2023 PATIENT ENROLLMENT FORM. TO GET STARTED, COMPLETE THE PATIENT ENROLLMENT FORM. YOUR HEALTHCARE PROVIDER MUST ALSO SUBMIT A HEALTHCARE PROVIDER ENROLLMENT FORM, FOUND AT WWW.MERCKACCESSPROGRAM-KEYTRUDA.COM/HCP. PLEASE COMPLETE THE SECTIONS ON THE FORM BELOW FOR THE SUPPORT YOU ARE REQUESTING.
To apply for the Merck Patient Assistance Program for KEYTRUDA ®, you must complete an Enrollment Form for the Merck Access Program. The Merck Access Program provides support to help answer questions related to insurance coverage and reimbursement.
GETTING STARTED IS SIMPLE – ENROLL NOW. Download and complete the patient sections of the enrollment form OR Use the electronic enrollment form; Print and fax the completed downloadable form to 855-755-0518 or submit the form electronically* A member from The Merck Access Program will reach out to you and your healthcare provider
The Merck Access Program is designed to provide reimbursement and insurance coverage-related information for your patient throughout their treatment process. SIGN & SUBMIT ELECTRONICALLY. DOWNLOAD & PRINT. Enrollment Form. Helpful Hints.
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