DOWNLOADS | PRESCRIPTION REIMBURSEMENT FORM
If for some reason you had to get your prescription filled at a pharmacy that does not participate with EHIM, and had to incur an out-of-pocket expense for the entire amount, you may be eligible for partial reimbursement. If you would like to be considered for reimbursement, submit this form, along with the pharmacy receipt (copies are acceptable) to EHIM.

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.