Get Nutrition Debit Card Program - Pertzye174

Filling out the Nutrition Debit Card Program - PERTZYE174 online is a straightforward process designed to help you access nutritional support through eligible prescriptions. This guide will walk you through each step to ensure you complete the form correctly and efficiently.

Follow the steps to successfully complete the Nutrition Debit Card Program form.

1. Press the ‘Get Form’ button to retrieve the Nutrition Debit Card Program - PERTZYE174 form and open it in your editor.
2. Begin by filling out your personal information. This includes your name, address, city, state, and ZIP code. Ensure that all entries are accurate to avoid processing delays.
3. Provide your contact information by entering your phone number and email address. This will facilitate communication regarding your application.
4. Affix your signature to the form, confirming that you are either the patient or a parent/guardian of a patient utilizing the debit card for nutritional needs.
5. Indicate the date you are completing the form. This helps with the timeline of your application.
6. Once the form is completed, gather a valid prescription receipt or invoice for your PERTZYE dispense, as this is required for your application.
7. Submit the completed form along with the prescription receipt to Chiesi CareDirect via mail, email, or fax. Make sure to check the contacts provided for each method.
8. Await a response from Chiesi CareDirect. They will contact you to finalize your enrollment and confirm your approval.
9. After you have received the card, you can take advantage of the benefits for nutritional supplements with your qualifying prescriptions.

Complete your Nutrition Debit Card Program - PERTZYE174 application online today!