Medication Shortage Request Form

If a health-system pharmacy is experiencing a critical shortage of a medication or medications, especially those related to the fight of the COVID-19 pandemic, the pharmacist-in-charge may complete this form, and submit it to the ICHP office. The request will be distributed to ICHP’s Pharmacy Director Network to identify possible alternative sources of the needed medications and connect those in need with those with supplies. The form must be completed by the pharmacist-in-charge at the health-system in need and all required information must be provided.