Admission Waiver Form - Minnesota Department of Health 2025

1. Click ‘Get Form’ to open the Admission Waiver Form in the editor.
2. Begin by filling out the Facility Information section. Enter your hospital name, trauma program manager's name, phone number, email, and trauma medical director's name and email.
3. In the Application section, list Level 1, 2, and 3 Trauma Hospitals for potential patient transfers. Estimate the time it would take for a patient to reach each hospital under normal conditions.
4. Next, identify EMS agencies that typically transfer trauma patients from your facility. Specify if they provide aeromedical, ground ALS, or ground BLS services.
5. Detail the types of trauma patients that may be admitted for observation and indicate which tertiary hospitals they may be transferred to.
6. Explain your specific request regarding circumstances preventing timely transfer to a tertiary hospital within 120 minutes.
7. Indicate whether the current admission and transfer policies are attached or if they were submitted with a previous application.
8. Attach a report detailing the number and types of trauma patients admitted and transferred over the past year.
9. Provide any additional information that supports your application before signing as CEO and dating the form.

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