Enrollment Form and Important Instructions

The Enrollment Form is the first step in obtaining information about insurance coverage for NEXPLANON for your patient. The Enrollment Form can be completed electronically or printed out and faxed to the Customer Support Center for NEXPLANON (CSCN).

If you have any questions about completing the Enrollment Form, please download and read the Important Instructions below or contact the CSCN directly.

Phone: (844) 639-4321
Fax: (844) 232-2618

Two ways to enroll your patients:

  1. Electronic Form
    • Follow link below to access the CSCN Provider Portal
    • Registration required
  2. Download Form
    • Download, print, complete, and fax
Copyright © 2019 Merck Sharp & Dohme B.V., a subsidiary of Merck & Co., Inc. All rights reserved. US-XPL-00347 03/19