Healthcare Grant Variance Form

HEALTHCARE GRANT VARIANCE FORM

Use this form to request a variance from an approved healthcare grant award. Complete all sections and attach supporting documentation. Submission constitutes a certification that the information provided is true and accurate and that the request is consistent with applicable grant terms, federal and state laws, and program requirements.

Grant Details

Patient Information (if applicable)

Insurance Information

Medical History Summary

Requested Variance

Variance type (select all that apply):

Line-Item Reallocation (if budget reallocation requested)

Fiscal Impact and Program Outcomes

Assurances, Certifications and Privacy Authorization

By submitting this request, the undersigned certifies that: (1) the information contained in this form and accompanying documentation is true, complete and accurate to the best of their knowledge; (2) any variance granted will be implemented in accordance with applicable grant terms, financial management standards, and record retention requirements; (3) the grantee accepts responsibility for any disallowed costs and agrees to repay funds if required; and (4) the grantee will cooperate with audits, monitoring, and programmatic reviews conducted by the grantor or its designees.

Authorization for Release of Protected Health Information (PHI): I authorize the release of the minimum PHI necessary for purposes of reviewing this variance request, including medical records, billing records, and programmatic reports. I understand this authorization is voluntary and that I may revoke it in writing except to the extent action has already been taken in reliance on this authorization. This authorization expires on the date entered below or upon completion of variance review.

Confidentiality Notice: Recipient records may be accessed by grantor staff, auditors, or other authorized reviewers. All parties will apply applicable privacy and confidentiality protections. The grantor's approval of a variance request does not alter obligations under law to protect patient privacy.

Attachments

Review Acknowledgment

Grantor review is required before any variance takes effect. Approval may be unconditional, conditional, or denied. If approved conditionally, the grantee must meet all stated conditions within the timeframe specified. Approval does not constitute amendment of the award beyond the variance as stated in formal written approval by the grantor.

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