Palynziq™ enrollment form

Complete and submit the form to Optum Frontier Therapies.


Sending your prescription for Palynziq

To submit a Palynziq prescription, the prescribing provider will need to complete a therapy enrollment form. The form can be downloaded below.

  • Once the prescribing provider completes and signs the enrollment form, the prescription is ready to submit.

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