Enroll Online

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

You can submit this documentation by:

MAIL:
Vitaflo® USA, LLC
Attn: Formula4Success
316 Montgomery St.
Alexandria, VA 22314

formula4success Enrollment Form

We'll be your power source! Vitaflo USA believes strongly that we have a duty to help you get the medical food products you need. The experts at formula4success are committed to making the process easier and less time consuming for you. Feel free to call us with questions: 1-888-848-2356
  • Patient Information

  • Healthcare Provider Information

  • Primary Insurance Information

  • Secondary Insurance Information

  • User your computer mouse to click and drag your signature. If you are using a touchscreen, you can use your finger to enter your signature.
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Privacy Statement & Authorization to Share Information:

Your privacy is important to Vitaflo USA, LLC (Vitaflo). Personal information collected by Vitaflo may be shared with Vitaflo’s affiliates, agents and contractors as well as other outside organizations (including healthcare providers, health plans and other product and service providers) to help provide patients with reimbursement support, including benefit verification, prior authorization and other reimbursement services. Additionally, Vitaflo and its affiliates and agents may use this information to contact patients about Vitaflo and its products and services. By submitting this information, I agree that Vitaflo and the outside organizations with which Vitaflo shares this information may contact me at any of the telephone numbers, including cell phone numbers, or email addresses provided. Vitaflo will not sell or rent personal information to others.

By agreeing to enroll in the formula4success program, you authorize Vitaflo and its contractors to have access to all medical and insurance coverage information and records that pertain to the patient listed on this form to verify insurance coverage for the Vitaflo product specified. You agree that Vitaflo will have no liability in providing these services and that the services may be changed or discontinued at any time without notice.

If you no longer wish to receive communications from Vitaflo and its affiliates and partners or want to revoke your consent to provide Vitaflo with access to medical and insurance coverage information, you may notify Vitaflo at any time via email at formula4success@VitafloUSA.com

IMPORTANT NOTICE: This information does not constitute legal advice or a recommendation related to medical necessity. All medical necessity determinations must be made by the responsible clinician. Providers are responsible for verifying accurate and appropriate claims for services. Vitaflo makes no representation or warranty regarding this information or its completeness, accuracy, timeliness, or applicability to a particular patient.

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Please note that enrollments received between OCTOBER 1 st – DECEMBER 31st will be processed in January 2018.
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