Form Doh 410-068 - Eip Exception Request - Washington Department Of Health Page 2

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Does insurance cover this
(if applicable)?
Have you requested an
exception to policy from
the insurance plan if
insurance does not cover?
Other resources (e.g.,
charity care, patient
assistance program) that
client has applied for
Please provide all supporting documents.
Requestor Signature:
Date:
I certify that the information provided on this form is true, accurate, and complete to the best of my knowledge.
CLIENT SERVICES USE ONLY
PROVIDER: DO NOT COMPLETE THIS PORTION
Reviewer Decision:
Approve
Deny
Cost:
Start Date
End Date
Signature
Date
DOH 410-068 July 2017

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