This form is only for approved New Mexico High-Fidelity Wraparound Provider Agencies to submit a request for a Waiver or Extension 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" button and your request will be expedited.

Waiver(s)/Extension(s) are temporary time limited waivers of program requirements where a provider agrees to return to program requirements after an agreed upon period or after certain conditions are met.

Please include:
1.  Name-Coach/Supervisor and Contact Information
2.  Name of person for which the Waiver/Extension will be applied, Contact Information, and Facilitator Current Status
3.  Challenge(s)/Issue(s) for the request. Historical background relevant to the situation
4.  Steps agency will take, or support your agency will need, to complete by Estimated Date of Completion
5. Estimated date that the conditions for this Waiver/Exception will be met

If you wish to receive a copy of  your submission, check "Send me a copy of my responses"

Direct any questions, or suggestions to improve this form or process, to Bob Brazell at bbrazell@nmsu.edu.