Appeals - Exception to Policy Request

Iowa Department of Human Services

Petition for Exception to Policy

Information About Person Filling Out Form

Name of person requesting the exception to policy

Phone number

Date of request

Company or Agency Name, if applicable

Email address

Address

City

State

Zip Code

Information About Person Who Needs Exception to Policy

Who is the exception to policy for

Social security or state ID number

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 month, 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?
If yes, please list name, address, and telephone number. Yes No

Do you know how the Department has treated similar situations?
If yes, please describe how the situation was handled. Yes No

Have you tried any other item or service before requesting an exception to policy?
If yes, please describe the item or service. Yes No

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 requested.

Signature of Requester

Date

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Confirmation #

Status

In Process

Submitted Date