Iowa Department of Human Services

PETITION FOR EXCEPTION TO POLICY


If you would like to submit a request for an exception to policy, please read the cover sheet and then complete the following information.  E-mail it to the Appeals Section by clicking the submit button at the bottom of the form.  If you have questions regarding this form, you may contact the Appeals Section at (515) 242-6302.

 

Name of person requesting the exception to policy:

Phone number:

Date of request:

Address:

City:

State:

Zip code:

E-mail address:

Social Security or State ID No:

Who is the exception to policy for:

Birth date:

Being specific, describe your request for an exception to policy:

What is the time period that you are requesting the exception to policy to cover (for example, one month, six months, etc.)?  The period cannot exceed one year. If the exception to policy is granted, and it is still needed after it expires, it may be renewed by submitting another request.

What is the date you would like the exception to policy to start?

Why are you requesting an exception to policy?

Does anyone else have information that would be helpful to the Department to make a decision on this request for a waiver?  Yes  No  If yes, please list name, address, and telephone number.

Do you know how the Department has treatment similar situations?  Yes  No

If yes, please describe how the situation was handled.

Have you tried any other item or service before requesting an exception to policy?  Yes  No

If yes, please describe the item or service.

If known, what rule are you requesting an exception to policy for?

I authorize any person with knowledge of the relevant or important facts relating to the requested waiver to release any information to the Department of Human Services.  I attest to the accuracy and truthfulness of the information contained in this request.

Signature of Requestor

Date

470-3888 (12/01)     Back to Appeals Page