Waiver dph 2026

1. Click ‘Get Form’ to open the waiver dph in the editor.
2. 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.
3. 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.
4. 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.
5. Provide an explanation of how adhering to the requirement would cause undue hardship, detailing any structural limitations and associated costs.
6. Assure that approval of this waiver will not compromise patient care or safety. Include relevant details about traffic flow and compliance with state codes.
7. Finally, have both the Facility Authorized Representative and Clinical Representative sign and date the form before submission.

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