The Merck Access Program 2021 Electronic Enrollment Form
This form can be signed and submitted electronically. Use this form only if the patient is in the office and you are able to complete the form together.
The Merck Access Program 2021 Electronic Health Care Provider Enrollment Form
This Health Care Provider form can be signed and submitted electronically. Please note that the patient must also submit the Electronic Patient Enrollment Form, which can be found at www.merckaccessprogram-ontruzant.com/hcc.
The Merck Access Program 2021 Enrollment Form
The Merck Access Program Sample Enrollment Form
Potential Independent Foundation Support
Prior Authorization Checklist
Sample Prior Authorization Letter
Sample Appeal Letter
Electronic Billing Guide
Sample CMS-1500 Form
Sample UB-04 Form
Physician Prescribing Information
The information available here is compiled from sources believed to be accurate, but Merck makes no representation that it is accurate. This information is subject to change. Payer coding requirements may vary or change over time, so it is important to regularly check with each payer as to payer-specific requirements.
The information available here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Merck and its agents make no warranties or guarantees, express or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs.
You are solely responsible for determining the appropriate codes and for any action you take in billing. Information about HCPCS codes is based on guidance issued by the Centers for Medicare & Medicaid Services applicable to Medicare Part B and may not apply to other public or private payers. Consult the relevant manual and/or other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes. Diagnosis codes should be selected only by a health care professional.
Abbreviation: HCPCS, Healthcare Common Procedure Coding Systems.