This form is only for approved New Mexico High-Fidelity Wraparound Provider Agencies to submit a request for a waiver or exception to be granted related to a specific policy or procedure in the Provider Manual and Implementation Guide. Requests will be routed to the appropriate authority and the sender will be notified of a decision within 2 weeks. If there is a time-sensitive urgency to the request please select the “urgent” box and your request will be expedited. Please include the following in the narrative section:

  1. Provider Name and Contact Information
  2. Name of person or persons the request will affect
  3. Reason for the request and if this is a request for a temporary waiver or an exception request.
  4. Any historical background relevant to the situation
  5. Length of Time the waiver will be in effect (when applicable)
  6. What the Provider will do to ensure return to normal operating procedure within the agreed upon timeframe
  7. What support the Provider is requesting from NM High-Fidelity Wraparound to address the situation that caused the need for the request

Provider Name and Contact Information

Urgency of request(Required)
Name of person or persons for which the exception and waiver request will be applied