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Get MA DPH Waiver Request Form

” sheets for clarification of specific physical plant condition to be waived. Physical plant waiver requests received without accompanying plans will be returned as “DENIED”. NOTE: A SEPARATE WAIVER REQUEST FORM MUST BE SUBMITTED FOR EACH REQUIREMENT FOR WHICH A WAIVER IS REQUESTED. Facility's Licensed Name or Proposed Name Address, including zip code If Hospital/Clinic Satellite, Name Address, including zip code Hospital/Clinic Department Building/Floor Location I HEREBY REQUEST TH.

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