Healthcare Waiver Request

HEALTHCARE WAIVER REQUEST

Use this form to request a waiver of a specific facility policy, clinical requirement, or administrative obligation. Submission of this request does not constitute approval. The facility retains sole discretion to grant, conditionally grant, or deny the waiver. Providing false or incomplete information may affect consideration and may subject the requester to any applicable penalties.

Patient Information

Insurance Information

Medical History (relevant to waiver)

Waiver Request Details

Indicate the specific waiver requested (check all that apply):

Vaccination exemption (medical or religious)

Mask/face-covering exemption

Deviation from standard clinical procedure or protocol

Visitation or accompaniment exception

Other (describe below)

Has the treating provider been informed of and involved in this request?

Yes

Risks, Benefits and Alternatives

I understand that granting a waiver may alter standard infection control, treatment, billing, or visitation practices. I acknowledge that the facility and its staff have explained, or offered to explain, potential risks and benefits of granting this waiver and any reasonable alternatives, which may include denial of the waiver or imposition of additional safeguards. I further acknowledge that the facility may impose conditions on any approved waiver to protect patient and staff safety.

I acknowledge and understand the stated risks and alternatives.

I agree to indemnify and hold harmless the facility and its employees from liability arising solely from the facility's accommodation of the requested waiver, except for willful misconduct or gross negligence.

Privacy and Authorization

I authorize the facility to review my medical record and any supporting documentation necessary to evaluate this request. I acknowledge receipt of the facility's privacy practices and understand that information necessary to evaluate this request may be disclosed to relevant staff and reviewers. This authorization is limited to information directly related to the waiver request and will expire on the waiver expiration date or upon revocation in writing.

I acknowledge and authorize the limited release of medical information for the purpose of waiver review.

Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that approval is not guaranteed, that approval may be conditional, and that the facility may rescind any approved waiver upon material change in circumstances or for failure to comply with conditions of approval. I understand that this waiver may affect insurance coverage and I am responsible for any charges not covered as a result of the waiver.

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