Form Doh 410-068 - Eip Exception Request - Washington Department Of Health
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2EIP EXCEPTION REQUEST
For eligibility, medication, and insurance premium exception requests.
(For exceptions for payment of medical procedures, medical or dental claims, please use Benefit Exception
Request form )
If the Early Intervention Program (EIP) approves the request, payment is still subject to all general conditions of the program.
CLIENT INFORMATION
Client Name
Leave this blank if you plan
to email this form back to
EIP
EIP ID Number
Date of Birth
REQUESTOR
Name
Leave this blank if you are
the client and you plan to
email this form back to EIP
Agency (If applicable)
Date of Request
EXCEPTION REQUEST
Reason for Request
Description
DOH 410-068 July 2017
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