Get Mn Sections 144g.45 Or 144g.81 Waiver Request 2021-2025

Filling out the MN Sections 144G.45 or 144G.81 Waiver Request form is essential for assisted living facilities seeking a waiver from specific statutory requirements. This guide will provide you with clear, step-by-step instructions to successfully complete the form online.

Follow the steps to complete your waiver request form.

1. Press the ‘Get Form’ button to obtain the waiver request form and open it in your preferred digital editing tool.
2. Select your request type by checking the appropriate box—either 'New waiver request' or 'Waiver renewal'—and proceed to the Licensee Information section.
3. Provide the required Licensee Information including facility license number, HFID number, facility name, physical address, city, state, zip, county, telephone, and fax.
4. Fill out the Requestor’s Contact Information by providing the legal name, telephone, and email address of the individual MDH can contact regarding your waiver request. If the authorized contact is different from the Assisted Living Facility Director, provide their contact details as well.
5. In the Waiver Details section, indicate the specific requirement for which you are requesting a waiver, the reasons for the request, and any alternative measures that will be implemented if the waiver is granted. Additionally, specify the length of time for which the waiver is requested and include any other relevant information.
6. If you are applying for more than one waiver, complete a separate Waiver Request for each one. If applying for only one, proceed to the Official Verification section.
7. Read and check each statement in the Official Verification section. Acknowledge your understanding and agreement by signing and providing the date.
8. After completing the form, ensure that you save your changes. You can download, print, or share the form as needed before submitting it to the Assisted Living Licensure email mailbox.

Complete your MN Sections 144G.45 or 144G.81 Waiver Request online today.