Care Provider/Pharmacy/Supplement Company Form - LivLyme Grant Kids

LivLyme Grant Recipient Families,

Completing this information entirely will enable us to prepare a care provider letter for your doctor, pharmacy or supplement company so they can be notified that your child received a LivLyme Kid Grant and will be given details on our payment processing procedures.

Please fill out the form completely.

Patient Information

Grant Recipient(Required)

First Last

Grant ID(Required)

Grant Recipient Birthdate(Required)

Parent Information

Parent Name(Required)

First Last

Parent Phone(Required)

Parent Email(Required)

Provider Information

Patient/Account Number at Provider's Office (if applicable)

Doctor’s Office

Pharmacy

Supplement Company

Provider Full Name (Doctor, Practitioner etc.)(Required)

Provider Title/Medical Designation(Required)

M.D. (Medical Doctor)

N.D. (Naturopathic Doctor)

D.O. (Doctor of Osteopathy)

N.P. (Nurse Practitioner)

P.A. (Physician Assistant)

Other

Please Specify

Billing Contact Name(Required)

First Last

Practice Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Phone(Required)

Billing Email(Required)

Pharmacy Information

If request is for a prescription from a pharmacy please complete:

Pharmacy Name

Pharmacy Address

Street Address Address Line 2 City State ZIP Code

Pharmacy Email (if applicable)

Pharmacy Billing Phone

Supplement Company Information

If request is for a prescription from a supplement company please complete:

Supplement Company Name

Supplement Company Address

Street Address Address Line 2 City State ZIP Code

Supplement Company Email (if applicable)

Supplement Company Billing Phone

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