Note: Fruitivits, Vitabites, SOS, and Single Dose Amino Acids are not eligible for Formula4Success.
Download the PDF enrollment form here, or simply fill in the secure online form below.
Patients are required to submit a prescription and a letter of medical necessity provided by your Healthcare Provider to be fully enrolled in the program. Letters of medical necessity templates can be found using the Letter of Medical Necessity link. Detailed Written Order (DWO) Templates can be found using the DWO link.
You can submit this documentation by:
Vitaflo® USA, LLC
PO Box 58569
Raleigh, NC 27658
formula4success Enrollment Form
Patient Authorization to Share Medical Information:
Required for Patient Enrollment
By signing below and submitting your information, you authorize Formula4Success for Vitaflo USA, Inc. (“Vitaflo”), to contact you and to collect your personal medical and insurance coverage information and share it with our agents and contractors as well as outside organizations (including healthcare providers and health plans), in order to verify insurance coverage and provide you with reimbursement support for Vitaflo products. You acknowledge that Vitaflo does not guarantee coverage by any insurance plan providers and will not reimburse any claims denied by third party providers. If you want to revoke your consent to access and share your information, you may notify us at any time via email at formula4success@VitafloUSA.com
IMPORTANT NOTICE: The information on this site is for informational purposes only and does not constitute legal advice. All medical necessity determinations must be made by the responsible clinician. Information on this site is obtained from third-party sources and is subject to change without notice due to frequently changing laws, regulations and guidance. Users should contact the appropriate payers for specific questions regarding coding, coverage, or reimbursement. Vitaflo does not guarantee coverage by any insurance plan and will not reimburse any claims denied by third-party payers.