Please read the accompanying Medication Guide for VERQUVO, including information about birth defects if taken during pregnancy, and discuss it with your doctor. The physician Prescribing Information also is available.
Please read the accompanying Medication Guide for VERQUVO, including information about birth defects if taken during pregnancy, and discuss it with your doctor. The physician Prescribing Information also is available.
To get started, select a category above or call 855-591-7980 to speak with a representative, Monday through Friday, 8 AM to 8 PM ET
Enroll With the Electronic Enrollment Form With E-Signature
Enroll With the Electronic Enrollment Form With E-Signature
REMEMBER TO: 
Sign & Submit Electronically
REMEMBER TO: Sign & Submit Electronically
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Use this option to complete the enrollment form electronically with the patient |
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Fill out and sign the healthcare provider section of the enrollment form |
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Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form |
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Submit the enrollment form electronically |
REMEMBER TO:
Download & Print
REMEMBER TO: Download & Print
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Download and print the enrollment form |
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Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
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Include a copy of the front and back of the patient’s insurance card |
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Fax the completed form to 833-996-3275 |
REMEMBER TO:
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Complete the patient and insurance information (page 1) |
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Fill out and sign the healthcare provider section of the enrollment form (pages 2-3) |
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Submit the enrollment form electronically |
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Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-verquvo.com/hcc/ |
