Healthcare Health Policy Waiver

HEALTH POLICY WAIVER

Patient Name:    Facility Name:

Effective Date of Waiver Request:

Patient Information

Emergency Contact

Insurance Information

Medical History (for clinical review)

Waiver Request — Policy Details

I request a waiver or exemption from the following health policy or requirement. I understand this request will be reviewed by clinical and administrative staff and may be granted with limitations or conditions.

Medical contraindication / clinical reason

Religious belief or practice

Personal preference

Other (explain below)

Acknowledgement of Risks, Release, and Conditions

By signing this waiver I acknowledge and agree to the following terms. These terms allocate responsibilities and are enforceable to the fullest extent permitted by applicable law.

1. Assumption of Risk: I understand that declining or receiving an exemption from the specified health policy may increase the risk of exposure, transmission, or adverse health outcomes to myself and others. I accept these risks knowingly and voluntarily.

2. Release and Waiver: I release and waive any claims against the facility, its directors, officers, employees, contractors, and agents (collectively the Facility Parties) for damages, costs, or losses arising directly or indirectly from the Facility's decision to grant or deny this waiver and from the consequences of granting this waiver, except for willful misconduct or gross negligence.

3. Indemnification: To the extent permitted by law, I agree to indemnify and hold harmless the Facility Parties from any third-party claims, liabilities, or expenses (including reasonable attorneys' fees) arising out of my request for the waiver or my actions while operating under the terms of an approved waiver.

4. No Guarantee of Accommodation: Approval of a waiver is discretionary. The Facility may impose conditions, restrictions, or monitoring requirements as a condition of approval. I understand that failure to comply with imposed conditions may result in revocation of the waiver.

5. Financial Responsibility: I understand that I may be responsible for additional costs associated with accommodations or alternative services required because of the waiver.

6. Right to Withdraw Request: I may withdraw this waiver request at any time. The Facility also reserves the right to withdraw or modify the waiver based on clinical, operational, or public health considerations.

HIPAA / Privacy Acknowledgement

I authorize the Facility to use and disclose my protected health information as necessary to evaluate this waiver request and to communicate with clinical reviewers, legal counsel, and administrative staff. I acknowledge that the Facility's Notice of Privacy Practices explains how my information may be used and disclosed.

I acknowledge receipt of the Facility's privacy practices and consent to the uses and disclosures described above.

Certification

I certify under penalty of perjury that the information I have provided in this waiver request is true, complete, and accurate to the best of my knowledge. I understand that providing false information may result in denial of the waiver and any other remedies available to the Facility.

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