THE MERCK PATIENT ASSISTANCE PROGRAM

Who is the program for?

Eligible patients with a prescription for WELIREG may be enrolled into the Merck Patient Assistance Program. Patients who do not have insurance or whose insurance does not cover WELIREG may be eligible for free product from the Merck Patient Assistance Program if they meet certain financial and medical criteria.

For more information on the program’s eligibility requirements, please visit www.merckhelps.com.

COMPLETE THE FORM BELOW

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

Patient and Physician Enrollment Form

Patient Enrollment Form

Physician Enrollment Form

SIGN & SUBMIT ELECTRONICALLY

DOWNLOAD
& PRINT

Patient and Physician
Enrollment Form

SIGN & SUBMIT
ELECTRONICALLY

DOWNLOAD
& PRINT

Patient Enrollment Form

SIGN & SUBMIT
ELECTRONICALLY

DOWNLOAD
& PRINT

Physician Enrollment Form

SIGN & SUBMIT
ELECTRONICALLY

DOWNLOAD
& PRINT

ENROLLMENT SUPPORT

Sample Enrollment Form

This form is a helpful resource that outlines important details and steps while you are filling out the enrollment form to ensure that all information and signatures are captured.

Submit Documents

Use this link to securely upload documents to submit to The Merck Access Program.