Relyvrio™ enrollment form
Complete and submit the form to Optum Frontier Therapies.
Sending your prescription for Relyvrio™
To submit a Relyvrio™ 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.