SAJAZIR™ enrollment forms

Complete and submit the forms to Optum Frontier Therapies.


Sajazir enrollment forms


Sending your prescription for SAJAZIR

To submit a SAJAZIR prescription, the prescribing provider will need to complete the therapy enrollment form and patient consent form. The form 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.