WELCOME TO
THE MERCK
ACCESS PROGRAM
ARE YOU A US HEALTH CARE PROFESSIONAL?
YES
NO

 

ENROLL NOW

Please click on the links below to access The Merck Access Program forms that are applicable to you. If you’re requesting a referral to The Merck Patient Assistance Program, be sure to include all information, including a prescription from your physician for KEYTRUDA.

Please be sure all signatures are included prior to faxing forms to The Merck Access Program.

DOWNLOAD FORMS

Work with your physician to download, print, and fill out the 2018 enrollment form.

Work with your physician to download, print, and fill out the 2019 enrollment form. Use this form to re‑enroll in The Merck Access Program.

Work with your physician to download, print, and fill out the 2018 Spanish enrollment form.

Work with your physician to download, print, and fill out the 2019 Spanish enrollment form. Use this form to re‑enroll in The Merck Access Program.


ELECTRONIC FORMS

Work with your physician to complete the 2018 enrollment form online prior to printing and faxing to The Merck Access Program.

Work with your physician to complete the 2019 enrollment form online prior to printing and faxing to The Merck Access Program. Use this form to re‑enroll in The Merck Access Program.

 
 

Contact The Merck Access Program Mon–Fri at 855-257-3932.