Wyoming Department of Health
Wyoming Department of Health
Aging Division - Healthcare Licensing and Surveys
Hathaway Building, Suite 510, 2300 Capitol Avenue, Cheyenne, WY 82002
Fax: (307) 777-7127 - Telephone: (307) 777-7123
E-mail: WDH-OHLS@ - Website: health.ohls
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|Request for State Licensure Rule Waiver |
In accordance with the Wyoming Department of Health, Public Health Emergency, Ch. 1, Emergency Rules for Licensing and Operations of Health Care Facilities, a Request for Agency Action is being made to waive specific licensure rules and regulations in order to manage and control the threat that COVID-19 presents to the public health. For questions related to waiver requests, please contact Healthcare Licensing and Surveys at 307-777-7123.
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|Facility name: | |Telephone: | |
| | |Email: | |
|Mailing address: | | | |
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|City: | |State/Zip: | |
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|Rules for which this waiver is being requested (chapter(s) and section(s)): |
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|Basis for Waiver |
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|The specific reason(s) for the request: |
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|By signing below, I attest that all information is correct. I also acknowledge that, if granted, this waiver will be approved until the end of the public |
|health emergency and the facility is able to return to normal operations. |
| | | |
|Administrator’s Name |Administrator’s Signature |Date Signed |
|HLS Office Use Only |
|HLS Comments: |
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| Approved |Signature-HLS Administrator: |Date Signed: |
| | | |
Please send completed form to: Tammy.Schmitt@
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HLS/Cons-119
Nov 16, 2011
HLS-019
May 06, 2020
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