Massachusetts waiver request 2026

1. Click ‘Get Form’ to open the Massachusetts Waiver Request 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 the name and address of any Hospital/Clinic Satellite.
3. Specify the Hospital/Clinic Department and Building/Floor Location where the waiver is being requested.
4. In section 1.A, clearly state your request for a waiver of compliance with the specific regulation or requirement. Include the citation in 1.B.
5. Describe in detail your proposed alternative to compliance in section 2.A. For hospitals and long-term care facilities, explain how you will compensate for this waiver in section 2.B.
6. Provide an explanation of how meeting the requirement would cause undue hardship in section 3.
7. In section 4, assure that approval of the waiver will not limit your capacity to provide adequate care and will not jeopardize patient or resident health and safety.
8. Finally, have both the Facility Authorized Representative and Clinical Representative sign and date where indicated.

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