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Get Merck Patient Assistance Attestation Form

N 1: Applicant Information (Patient should complete all information in Section 1.) Patient s First Name US Resident* Yes No Male Female Last Name Address Apt. No. City State Phone ZIP Date of Birth Gender M M D D Y Y Y Y Do you have Medicare insurance? Yes No Medicare beneficiaries only: Do you have Medicare Part D? Yes No Do you have any other health insurance coverage of any kind (public or private)? Yes No Examples: Medicaid, veterans benefits.

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