DOWNLOADS | QUANTITY LIMIT MEDICAL NECESSITY REQUEST
This form should be used to request specific quantities of a requested medication.

Download the form (PDF).

Instructions

Filling out all fields in the form is is REQUIRED in consideration of approval for the prescribed quantity. Incomplete forms will be returned for additional information. Please fax the completed form to:

EHIM
Attn: Clinical Department
248-204-5604

If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.