Sections 144G 45 or 144G 81 Waiver Request Assisted living licensure form 2026

1. Click ‘Get Form’ to open the Sections 144G 45 or 144G 81 Waiver Request form in the editor.
2. Begin by selecting your request type: either 'New waiver request' or 'Waiver renewal'. This helps categorize your submission.
3. Fill out the Licensee Information section, providing details such as the facility license number, HFID number, facility name, and contact information.
4. In the Requestor’s Contact Information section, enter the legal name and contact details of the individual MDH can reach for questions regarding this waiver request.
5. Detail your Waiver Details by specifying the requirement for which you are requesting a variance, along with reasons and alternative measures if granted.
6. Complete the Official Verification section by checking each statement to confirm your understanding and agreement. Sign and date where indicated.

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