The Department may waive the applicability to a particular clinic of one or more of the requirements imposed on clinics by 105 CMR 140.000 if:

1. (A) the Department finds:

   1. (1) compliance would cause undue hardship to the clinic;
   2. (2) the clinic is in substantial compliance with the spirit of the requirement; and
   3. (3) the clinic’s noncompliance does not jeopardize the health or safety of its patients and does not limit the clinic’s capacity to give adequate care.
2. (B) the clinic provides to the Department written documentation supporting its request for a waiver.