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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.

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Co-pay Assistance Options for Eligible Patients

The Merck Patient Assistance Program

Support Resources

Healthcare Professionals Patients and Caregivers

Medication Guide Physician Prescribing Information En Español

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

Learn More About Enrollment

THE MERCK ACCESS PROGRAM

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 healthcare provider for VERQUVO. Please be sure all signatures are included prior to submitting forms to The Merck Access Program.

DOWNLOAD & PRINT

This form can be downloaded and printed, and requires an original signature. Work with your healthcare provider to complete and submit the enrollment form.

Enrollment Form

SIGN & SUBMIT ELECTRONICALLY

This patient form can be signed and submitted electronically. Please note that your healthcare provider must also submit the Healthcare Provider Enrollment Form.

Electronic Patient Enrollment Form

Please click here to access The Merck Access Program Enrollment Form for VERQUVO in Spanish

ENROLLMENT SUPPORT

Patient Representative’s Form

Do you have a legal and/or personal representative who is helping you with your application? If so, this person must fill out this form and fax it to 833-996-3275.

	Use this option to complete the enrollment form electronically with the patient
	Fill out and sign the healthcare provider section of the enrollment form
	Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form
	Instruct the patient to complete and sign the patient sections of the enrollment form
	Submit the enrollment form electronically

	Download and print the enrollment form
	Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4)
	Fill out and sign the healthcare provider section of the enrollment form (pages 5-6)
	Include a copy of the front and back of the patient’s insurance card
	Fax the completed form to 833-996-3275

	Complete the patient and insurance information (page 1)
	Fill out and sign the healthcare provider section of the enrollment form (pages 2-3)
	Submit the enrollment form electronically
	Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-verquvo.com/hcc/