Patients should speak with their health care professional about which vaccines may be right for them.

To participate in the program, patients and their licensed prescribers (e.g., physicians, nurse practictioners and physician assistants) must:

1.	Complete and sign an application form
	English   [PDF*: 565 KB, 2 pages] Spanish  [PDF*: 91 KB, 2 pages]
	Licensed prescribers and their office personnel can also call (800) 293-3881 toll free to obtain enrollment applications for patients and to request additional information about the program.
2.	Fax completed form to (800) 528-2551 from a participating Licensed Prescriber's Office.

The application must be submitted and approved prior to administration of vaccine in order to qualify.

Forms will be processed quickly^a – with a goal of less than 10 minutes – and the Licensed Prescriber's Office will be notified by phone so that qualifying patients can receive the Merck vaccine during that visit.

A new application will need to be completed and submitted to the Merck Vaccine Patient Assistance Program for eligibility assessment prior to a patient receiving a subsequent dose in a multi-dose series or for another Merck vaccine.

^a During business hours (8:00 AM–8:00 PM EST Monday - Friday)