Get Variance Request Application - Utah Department Of Health - Health Utah

Filing a Variance Request Application can be a vital step for facilities seeking adjustments to licensure rules. This guide provides clear, step-by-step instructions to assist you in completing the Variance Request Application online, ensuring that your submission is thorough and accurate.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it for editing.
2. In the identifying information section, enter the name of your facility, your telephone number, and address, including the city, state, and ZIP code.
3. Next, provide the rule number from which the variance is being requested, including the title and the section number.
4. Indicate the time period for which the variance is requested, ensuring to mention specific dates if applicable.
5. Answer whether the facility is currently licensed by selecting 'Yes' or 'No.' If 'Yes,' provide the expiration date and if 'No,' indicate the anticipated application date.
6. In the facts forming the basis for variance section, clearly explain the specific reason for the request and detail why compliance with the rule cannot be accomplished.
7. Describe how the health and safety of patients and residents will be maintained if the variance is approved.
8. If the variance involves the physical structure or equipment, specify the exact location within the facility where the variance will be utilized.
9. In the notification of interested parties section, list the names and addresses of any parties who have been informed about this request.
10. Finally, complete the certification of request section by providing your name, title, signature, and date.
11. After filling out all relevant sections, ensure to review your information for accuracy. Once validated, you can save changes, download, print, or share the completed form.

Complete and submit your Variance Request Application online to ensure your facility's compliance and continued operation.