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