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Quantity Limit Medical Necessity Request

Download the Form

This form should be used to request specific quantities of a requested medication. Filling out all fields in the form is required in consideration of approval for the prescribed quantity. Incomplete forms will be returned for additional information. Please fax the completed form to:

Attn: Clinical Department

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