Enroll Online for the Vitaflo Personalized Support Program

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:

EMAIL:
formula4success@VitafloUSA.com

FAX:
1-888-485-7193

MAIL:
Vitaflo® USA, LLC
Attn: Formula4Success
PO Box 58569
Raleigh, NC 27658

formula4success Enrollment Form

Patient Information
Patient's legal name*
First Last
Gender of patient*
- Male
- Female
Patient's date of birth*
MM slash DD slash YYYY
Name of parent or legal guardian (if patient is under age 21)
First Last
Shipping address*
Street Address Address Line 2 City State ZIP Code
Preferred phone number*
Email address*
Enter Email Confirm Email
Vitaflo product(s) name requested*
Healthcare Provider Information
Healthcare Provider’s Name*
Is the provider listed a doctor or dietitian?*
- Doctor
- Dietitian
Provider’s Email*
Provider's phone number*
Clinic*
Clinic address*
Street Address Address Line 2 City State ZIP Code
Primary Insurance Information
Insurance Provider*
Policy holder's name*
First Last
Group ID*
Member ID*
Insurance provider services phone number*
Pharmacy services phone number
Member services phone number
Secondary Insurance Information
Insurance Provider
Policy holder's name
First Last
Group ID
Member ID
Insurance provider services phone number
Pharmacy services phone number
Member services phone number
DO YOU AGREE? PLEASE CHECK.*
- I have read and agree to the Privacy Statement & Authorization to Share Information.
DO YOU GIVE CONSENT? PLEASE CHECK.*
- I give my consent to enroll in the formula4success program.
Signature
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.
Hidden
Submission Date
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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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.

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formula4success Enrollment Form

Patient Information

Healthcare Provider Information

Primary Insurance Information

Secondary Insurance Information

Patient Authorization to Share Medical Information:

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Formula4Success

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formula4success Enrollment Form

Patient Information

Healthcare Provider Information

Primary Insurance Information

Secondary Insurance Information

Patient Authorization to Share Medical Information:

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Formula4Success

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