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TREATMENT EXCEPTION REQUEST FOR PROVIDER USE ONLY (PLEASE PRINT CLEARLY) Please Fax Completed Form to Health PAC HIV at 5105676850 TELEPHONE: 5103831790 *PATIENT INFORMATION: *PHARMACY INFORMATION:
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Ter form 82012-1docx is a tax form used for reporting certain types of income.
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Individuals or businesses who have received income that needs to be reported on this form are required to file ter form 82012-1docx.
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Information such as income amounts, payer information, and any relevant deductions or credits must be reported on ter form 82012-1docx.
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