DOWNLOADS | CLINICAL MEDICAL RELEASE FORM
Due to HIPAA Regulations, EHIM now requires a Clinical Medical Release Form on file. This form gives EHIM the legal right to speak with the doctor designated on the form about your medical history. This is necessary when gathering information when a Prior Authorization has been requested. Please note that a Prior Authorization can not be processed without this form on file.

Download the form (PDF).


Instructions

The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.