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How to use or fill out waiver dph with our platform
- Click ‘Get Form’ to open the waiver dph in the editor.
- Begin by entering the Facility's Licensed Name or Proposed Name along with the complete address, including zip code. If applicable, provide details for any Hospital/Clinic Satellite.
- In the section requesting a waiver, specify the regulation or requirement you are seeking to waive. Include the citation and text of the regulation that requires compliance.
- Describe your proposed alternative to compliance in detail. Clearly outline how you plan to maintain safety and care standards despite not meeting the original requirement.
- Provide an explanation of how adhering to the requirement would cause undue hardship, detailing any structural limitations and associated costs.
- Assure that approval of this waiver will not compromise patient care or safety. Include relevant details about traffic flow and compliance with state codes.
- Finally, have both the Facility Authorized Representative and Clinical Representative sign and date the form before submission.
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