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:
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.
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:
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.
