Exceptional Case Status — Variation or Interruption to Care form

Form ID
D1307
Audience
Registered Nurse
For providers

This form is used to request a variation or extension to Exceptional Case Status.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
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Form (PDF or Word)