Request a waiver for requirements of 105 CMR 722

What you need

• The health care facility’s (hospital) licensed name
• MA DHCFLC hospital license number
• Address, including zip code
• MA Controlled Substance Registration
• A list of MA Schedule VI controlled substance(s) included in the waiver
• Information of the facility authorized representative:
  • Name
  • Title
  • Mailing address
  • Phone number
  • Signature
• Information of the facility clinical representative:
  • Name
  • Title
  • Mailing address
  • Phone number
  • Signature

How to request

By mail +

1. Download and complete the Hospital Request Form for Waiver of Requirements 105 CMR 722 - Dispensing Procedures for Pharmacists
   • Note: a separate waiver request form must be submitted for each requirement to be waived.
2. Mail the completed form to:
   
   Department of Public Health
   Division of Health Care Facility Licensure and Certification
   67 Forest Street
   Marlborough, MA 01752

Contact

Division of Health Care Facility Licensure and Certification

+

Address

67 Forest St., Marlborough, MA 01752

Directions 

Phone

Call Division of Health Care Facility Licensure and Certification at (617) 753-8000

Related

• 105 CMR 722.00: Dispensing procedures for clinic and hospital pharmacies