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Request for Addition to Central Health Floor Stock Formulary

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Do not submit Protected Health Information (PHI) on this request form.

Complete the form below, or download a PDF, complete, and return.

MM slash DD slash YYYY
Name of Requesting Provider
(e.g., tablets, liquid, etc.):
On CH floor stock formulary
On MAP/MAP basic formulary
Max. file size: 80 MB.
(i.e., black box warning, precautions, adverse effects, appropriate for clinic administration, monitoring parameters, etc.)