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Medical Information Release

  • Member Information
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    • HRA Reimbursement Form
    • HRA Rx Reimbursement Form
    • HIPAA Forms
    • Medical Information Release
    • OptumRx Mail Order
    • Prescription Reimbursement
    • Prior Authorization
    • Quantity Limit Medical Necessity PPI
    • Quantity Limit Medical Necessity Request
    • Step Therapy Medical Necessity
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    • MAC List Appeal Form
    • TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals

Resources

Medical Information Release

Download the Form


EHIM requires a HIPAA release form on file to allow access to prescription histories. This form gives EHIM the legal right to release the prescription utilization history. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.

  • Member Information
    • Special Medical Reimbursement Program
    • FSA Management
    • HRA Management
    • Debit Card Program
    • Dental Plan Administration
    • FAQs
  • Downloadable Forms
  • Employer
    • COBRA Event
    • Enrollment or Termination
    • Medicare Part D Forms
  • Member
    • Clinical Medical Release
    • FSA Dependent Care Reimbursement
    • FSA Healthcare Reimbursement
    • HRA Reimbursement Form
    • HRA Rx Reimbursement Form
    • HIPAA Forms
    • Medical Information Release
    • OptumRx Mail Order
    • Prescription Reimbursement
    • Prior Authorization
    • Quantity Limit Medical Necessity PPI
    • Quantity Limit Medical Necessity Request
    • Step Therapy Medical Necessity
    • Walgreens Mail Order Registration
    • Walgreens Mail Order Physician Fax
    • Formulary
  • Pharmacy
    • MAC List Appeal Form
    • TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals

Resources

Medical Information Release

Download the Form


EHIM requires a HIPAA release form on file to allow access to prescription histories. This form gives EHIM the legal right to release the prescription utilization history. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.


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  • Contact Us
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