Free Health Care Facility Assurances for - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 43006 (Rev. 10//06)

STATE OF WISCONSIN USDOS, 22 CFR 41.63 (608) 266-1568

HEALTH CARE EMPLOYER ASSURANCES FOR J-1 VISA WAIVER APPLICATIONS
(Completion of this form satisfies the employer assurances required under U.S. Department of State regulations 22 CFR 41.63. Failure to complete this form will result in an application being deemed ineligible for a state recommendation for a J-1 visa waiver.)

The health care employer requesting this J-1 visa waiver recommendation, assures that each of the following statements are factual. The employer's authorized representative must initial each statement and must sign and date the bottom of this Health Care Employer Assurances form. ____ 1. The practice address stipulated in the employment agreement is in a geographic area federally designated Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), or Medically Underserved Population (MUP). Requestors for an exception for a practice address not located in a HPSA, should write-in "N/A". ____ 2. As indicated in the employment agreement, the applicant physician will provide medical services (primary care, mental health, or other specialty) for a minimum of 40 hours per week, for a period of three years, and only at the practice address specified in the employment agreement (see #1 above). ____ 3. The applicant physician will begin working for the health care employer within 90 days of the effective date of the J-1 visa waiver. ____4. The health care employer commits to make reasonable effort to retain the applicant physician for at least three years, e.g. an employment package that is competitive for the service area and the physician's qualifications/performance. ____ 5. The health care employer accepts Medicaid and Medicare eligible patients, as well as medically indigent patients. NOTE: There are consequences for employer failure to comply with Wisconsin J-1 visa waiver program requirements. See "Wisconsin Guidelines for State Recommendations for J-1 Visa Waivers" available at: http://dhfs.wisconsin.gov/localhealth/J_1VISA/ I, the authorized representative of the health care employer submitting this application, do assure that each of these statements are factual. ___________________________________________________ Print Name and Title of Authorized Employer Representative ___________________________________________________ Print Name of Health Care Employer ___________________________________________________ SIGNATURE - Authorized Employer Representative ___________________ Date Signed