NITYR^® enrollment forms

Sending your prescription for NITYR

To submit a NITYR prescription, the prescribing provider will need to complete a therapy enrollment form and also supply a patient consent form. Both forms can be downloaded below.

• When filling out the therapy enrollment form, be sure to note Optum Frontier Therapies as your preferred pharmacy.
• Once the prescribing provider completes and signs the enrollment form, and the patient completes and signs the patient consent form, the prescription is ready to submit.

Find more information on the three ways to send us a prescription here.

Download enrollment and consent form