Exception Request to the Division of Acute and Ambulatory Care

Exceptions Request Division of Acute and Ambulatory Care

Name of Facility ______

Facility CEO ______

Address of Facility ______

Phone Number ______Fax Number______

Description of Exception Request:

Specific regulation (for example, 107.62) for which the facility is requesting an exception and why granting this exception is deemed necessary and would benefit patient care and safety:

If the facility is requesting an exception to the construction guidelines, you must refer to the specific American Institute of Architects (AIA) guideline you are requesting, for example, 7.7.C7 Clean workroom or clean supply room. Please attach the narrative for the construction/renovation.

Description of how the facility will assure that such exceptions will not adversely affect patient care:

______Signature of CEO/ individual appointed by the Governing Body

 The Exceptions Request form can be saved as a word documented and text inserted.  In addition to completing the Exceptions Request form, a letter may be submitted for Committee review and consideration.  The CEO/ person appointed by the Governing Body of the facility who is responsible for the management and operations of the facility must sign the Exceptions Request form and letter, if one is submitted.  Mail request to: Joanne Salsgiver, RN, MHA Director Division of Acute and Ambulatory Care Room 532, Health and Welfare Building Harrisburg, PA 17120