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Pricing Complaint

To file a formal complaint about a pharmacy you believe has been conducting unfair prescription drug pricing: Please fill out this form online, or download a copy and mail it to the Michigan Department of Community Health (see form for mailing instructions).

Your Contact Information

Name:
Email:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:

Pharmacy Information

Name:
Address:
City:
State:
Zip Code:
Business Phone:

Details

Medication:
Date of Purchase:

Why you believe the medication was unfairly priced:

Additional Comments:

 

     
 

 

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