Appendix C Physician National Interest Waiver Program by State

• Jurisdiction: United States

ALABAMA

Chuck Lail

334-206-5438

chuck.lail@adph.state.al.us

Website: http://www.adph.org/ruralhealth/Default.asp?id=911

Designation Areas Accepted

HPSA, MUA & MUP

Definition of Primary Care

Family Practice, Internal Medicine, Pediatrics, OB/GYN, Psychiatry; Geriatrics is considered part of Internal Medicine and qualifies as PC

Special Application Requirements

Current Alabama J-1 Participants

1) Employer letter

2) Addendum to J-1 employment contract with NIW Liquidated Damages Clause, provision incorporating NIW Physician Affidavit & Agreement & NIW Physician Guidelines, & cover a cumulative term of 5 years.

3) Signed & notarized NIW Physician Affidavit & Agreement & Alabama NIW Guidelines

Non-Alabama J-1 Participants

1) Employer letter

2) Sliding fee scale & plan for its implementation, description of service for past 3 years (only for primary care physicians) & public notice advising patients of site’s commitment to serve all patients.

3) DS-3035 & related information required by DOS, copy of I-94 or other U.S. immigration documents.

4) Alabama NIW Guidelines & signed NIW Physician Affidavit & Agreement -March 2016 editions;

5) Signed employment contract, with VERBATIM NIW Visa Liquidated Damages Clause, no non-compete clauses, commits clinic-based primary care physicians to 40 hours of in clinic service, must affirm physician will adhere to community standards regarding hospital emergency department coverage, start date within 90 days of the waiver, no blank spaces subject to later entries, cannot pre-date any required physician recruiting documentation;

6) Physician’s CV, letters of recommendation, & credentials including Alabama Medical License or a copy of the application;

7) DS-2019s & other U.S. immigration documentation showing physician’s current legal status & history of stay in the U.S.;

8) Copies of ads & supporting documentation showing efforts within past 6 months. All recruitment must be done before executing an employment contract with the physician.

Other

The time previously served in J-1 waiver service may be counted toward NIW service. Sub-specialists must provide letters of support for government leaders and professional entities representing the local service area’s medical profession at large. NIW physician employers must establish that they have operations that are well established and principally engaged in providing the type of care that will be provided by the NIW physician. A commitment must be made by both the employer and NIW physician to use a sliding fee scale to reduce the payment obligation of uninsured, medically indigent patients. Use of the sliding fee scale guidelines must be detailed in an implementation plan which must be developed by the employer and included in the application. Facility must provide reports to the department every 6 months.

ALASKA

Jerrine Regester

907-465-5669

Jerrine.Regester@alaska.gov

Designation Areas Accepted

HPSA & MUA

Definition of Primary Care

N/A

Special Application Requirements

1) Letter from employer requesting the NIW; 2) Employment contract; 3) Physician’s CV.

Other

Alaska does not receive many requests for NIW support letters and therefore has no formal regulations for issuing NIW letters.

ARIZONA

Ana Lyn Roscetti

602-542-1066

Ana.lyn.roscetti@azdhs.gov

Website: http://www.azdhs.gov/hsd/workforce/national-interest-waiver.htm

Designation Areas Accepted

HPSA, MHPSA, MUA & MUP

Definition of Primary Care

Family Practice, General Practice, General Internal Medicine, Pediatrics, OB/GYN & Psychiatry

Special Application Requirements

1) National Interest Waiver application form;

2) Letter from the physician asking ADHS for the NIW recommendation, including a description of physician’s qualifications, work schedule and duties;

3) Full-time employment contract. If IMG is self-employed, must submit a copy of the lease or purchase agreement for the premises where the physician practices or other proof of the practice site;

4) Notarized Statement of Understanding and Agreement;

5) Current SFS & procedure for its use (must be submitted each year for review and approval);

6) Notarized Certification of Service Site.

Other

Will consider requests only from physicians who obtained J-1 waivers through ADHS. Accepts specialist physicians. Physician must have practiced on a full-time basis at a qualifying approved site located in a federally designated area for at least 1 year immediately preceding the request or have completed J-1 waiver service within a year prior to request.

The 5-year period is counted from the date physician begins practicing in a federally designated shortage area under a J-1 visa waiver based on an ADHS letter of support, after receiving an H-1B visa.

ARKANSAS

Jane Gaskill

501-661-2201

Jane.Gaskill@arkansas.gov

Website: http://www.healthy.arkansas.gov/programsServices/hsLicensingRegulation/HealthFacilityServices/Pages/J-1WaiverProgram.aspx

Designation Areas Accepted

HPSA, MHPSA, MUA, MUP & Facility Designation

Definition of Primary Care

Family Practice, Internal Medicine, Pediatrics, Gerontology, OB/GYN & Psychiatry

Special Application Requirements

1) NIW request letter from attorney including worksite information;

2) Copy of DS-3035 with third party barcode page;

3) DOS case file number on all pages of the application;

4) Current Arkansas medical license;

5) 5-year employment contract, including physician’s name, physician’s medicasl specialty, practice site address(es), days & hours to be spent at each practice site, practice site designation ID number(s), statement physician will work minimum of 40 hours per week, salary, start date, statement that physician and employer agree to comply with INA, signatures of both physician & head of the facility, & date the contract was signed. Cannot include any restrictive covenants.

Other

NIW requests accepted in 3 situations:

1) Qualified physicians placed through the Arkansas J-1 Visa Waiver Program/Conrad 30;

2) Physicians under current contract to Arkansas Community Health Centers (CHCs) or Federally Qualified Health Centers (FQHCs); or

3) Requests by Arkansas providers in designated MUAs or HPSAs, or serving designated MUAs or HSPAs, who have entered into an employment contract with a physician on an H-1B visa.

NIW letter will be sent to the requesting attorney.

CALIFORNIA

April Freitas

916-449-5757

April.freitas@dhcs.ca.gov

Designation Areas Accepted

HPSA, MUA & MUP

Definition of Primary Care

Family Medicine, General Pediatrics, General Obstetrics, Internal Medicine, Psychiatry

Special Application Requirements

1) Letter from the physician’s attorney requesting the NIW support letter on the physician’s behalf, which must include the physician’s name, the physician’s field of medicine, the employer’s name, the address(es) of the service site(s), the service site(s) effective date, a description of the nature and extent of the medical services to be provided by the physician applicant, a description of the service area demographics (income, average Federal Poverty Level, primary language, age make-up of the residents, patient population mix, and other pertinent information to illustrate the community to be served by the physician), 2 signed and notarized (with Jurat verbiage) attestations:

a) the physician will practice at least 40 hours per week for 5 years, with specific start and end dates, and

b) the physician will comply with the federal NIW requirements;

2) Legible copy of the signed and dated employment agreement between the physician and employer, that includes the start and end dates of the employment, the type of services to be provided, the address(es) of the service site(s), and a statement that the physician will work for a minimum of 40 hours per week;

3) Proof of the facility’s HPSA, MUA, MUP, or MHPSA designation status.

4) Copy of the physician’s California medical license or a copy of the application for the medical license and proof of receipt of the application from the Medical Board of California;

5) Physician’s CV;

6) Completed California Authorization for Release of Information form (http://www.dhcs.ca.gov/services/rural/ Documents/ AuthRelInfo_Jan_2016.pdf);

7) Completed Form G-28.

Other

A medical fellowship or any other specialty medical training after the residency has been completed cannot be used to satisfy any portion of the 5-year service requirement. If the employment agreement

does not cover a 5-year period, the physician must provide proof of previous employment in a federal designated shortage area or VA facility and also provide proof of the facility’s HPSA, MUA, MUP, or MHPSA status for the previous employers. If the physician plans to establish his/her own practice, he/she must submit a notarized statement (with Jurat verbiage) agreeing to work 40 hours a week in a clinical practice for the NIW period. Must also describe the steps taken or will be taken to establish the practice. Must include terms of employment with start and end dates. Application must be mailed; it cannot be e-mailed. Review is 21 business days.

COLORADO

Kent O’Connor

303-692-6399

kent.oconnor@state.co.us

Website: https://www.colorado.gov/pacific/cdphe/national-interest-waiver-program

Designation Areas Accepted

HPSA, MHPSA & MUA/MUP

Definition of Primary Care

Family Practice, General Practice, Internal Medicine, OB/GYN, Pediatrics, Psychiatry

Special Application Requirements

1) NIW application form;

2) Employer statement on official letterhead explaining how physician will satisfy medical needs, percentage of medically underserved patients, description of the location, and how a denial will have a negative impact;

3) Proof of serving underserved including designation number, notice of sliding fee, policy for using sliding fee, and copy of sliding fee scale;

4) 5-year contract for full time employment, must include: description of primary or specialty care to be provided, start date, description of care for uninsured & those with Medicare & Medicaid. Cannot contain...