MICHIGAN DEPARTMENT OF COMMUNITY HEALTH (MDCH) by 9DvZVQ

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									         MICHIGAN DEPARTMENT OF COMMUNITY HEALTH (MDCH)
           BUREAU OF FAMILY, MATERNAL AND CHILD HEALTH
             DIVISION OF FAMILY AND COMMUNITY HEALTH

                       Maternal Infant Health Program (MIHP)
              Professional Staff Waiver Application/Assurance Statement

To request a staffing waiver for MIHP, the certified MIHP provider must submit:

A cover letter which includes the following:

   1.      The reason why the agency is requesting the waiver;

   2.      A detailed description of the actions taken to employ a qualified professional;

   3.      A copy of the waiver applicant’s resume or curriculum vitae, which includes
           work experience;

   4.      A copy of applicable license and/or registration;

   5.      Orientation Plan (recommended outline enclosed);


   NOTE: The waiver packet must be approved by MDCH prior to the assignment of
         the professional for whom the waiver is being requested to MIHP. The
         Michigan Department of Community Health will review and approve or
         deny your waiver request in writing, within 30 working days of receipt of
         the request.

             A “Notice of Waiver Completion” form is attached and must be returned to
             MDCH upon completion the staff orientation.

   Please return all materials to:

   Ingrid Davis, M.P.A.
   MIHP Consultant
   Michigan Department of Community Health
   P.O. Box 30195
   Lansing, Michigan 48909


   Email Address: Davisi1@michigan.gov
   Phone Number: 517 335-9546

								
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