Please click on the links below to access The Merck Access Program forms that are applicable to you. If you are requesting a referral to the Merck Patient Assistance Program. be sure to include all information, including a prescription from your health care provider for RENFLEXIS. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
DOWNLOAD & PRINT
These forms can be downloaded and printed, and require an original signature. Work with your health care provider to complete the enrollment form.
Use this form to re-enroll in The Merck Access Program.
NEW SIGN & SUBMIT ELECTRONICALLY
This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the Health Care Provider Enrollment Form.