Free 50775.PDF - Indiana

INDIANA STATE DEPARTMENT OF HEALTH INDIANA HEALTH CARE PROFESSIONAL RECRUITMENT AND RETENTION FUND Health Care Professional Student Loan Repayment Program STUDENT LOAN REPAYMENT APPLICATION Program Description: The Indiana Health Care Professional Recruitment and Retention Fund Program (IHCPRRF) provides loan repayment for student loans incurred by health care professionals to encourage the full-time delivery of health care in shortage areas. The Indiana State Department of Health (ISDH) administers the fund. Primary Care Physicians (MD and DO) (family practitioners, internists, pediatricians, obstetricians and gynecologists); Primary Care Nurse Practitioners (NP); Certified Nurse Midwives (CNM); Primary Care Physician Assistants (PA); General Practice Dentists (DDS or DMD), and Dental Hygienists (DH) are eligible for the student loan repayment program. Physicians who have not completed a residency training program are not eligible for the student loan repayment program. § § § The IHCPRRF Program allows the ISDH to repay outstanding student loans only, for expenses incurred during undergraduate or graduate education Health care professionals participating in the IHCPRRF Program must practice in public or private not-for-profit settings in federally designated shortage areas approved by the ISDH and, therefore, cannot establish private practices. Loan repayment awards are considered personal income and are taxable.

Loan Repayment Awards: Health care professionals may be granted up to the following amounts: Service Year 1 2 Total IHCPRRF Award $20,000 $20,000 $40,000

Health Care Professional Requirements: Y Must be U.S. citizens. Y Must agree to provide services in an ISDH-approved, federally designated underserved area for two years. Y Must not have an outstanding contractual obligation for health professional service to the federal government or a state or other entity unless that service obligation will be completely satisfied before the contract has been signed. Y Must not be in breach of a health professional service contract to the federal government, a state or local government, or other entity. Y Must not have a judgment lien against their property for a debt to the U.S. Y Must perform the service obligations at an eligible site, i.e., public or nonprofit private entity located in a federally designated HPSA appropriate for their discipline and providing primary health care services.

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Y

Y

Y

Y

Y

Must provide full-time primary health care services, which is defined as a minimum of 40 hours per week for at least 45 weeks per year for two years at an eligible site. At least 32 of the minimum 40 hours per week must be spent providing clinical service. These services must be conducted during normally scheduled clinic hours in the ambulatory care setting office(s), with the remaining hours spent providing inpatient care to patients of the eligible site and/or in practice-related administrative activities, with administrative activities not to exceed 20 percent of their full-time tour. Obstetricians/Gynecologists and certified nurse midwives are expected to spend not less than 21 hours per week providing ambulatory care services during normally scheduled office hours, with the remaining hours spent providing inpatient care to patients of the eligible site and/or in practice-related administrative activities, with administrative activities not to exceed 20 percent of their full-time tour. Must charge for their professional services at the usual and customary prevailing rates in the area in which such services are provided, except that if a person is unable to pay such charge, such person shall be charged at a reduced rate or not charged any fee. Must agree to provide primary health care services to any individual seeking care. The IHCPPRF Program participants must agree not to discriminate on the basis of the patient's ability to pay for such care or on the basis that payment for such care will be made pursuant to Medicare or Medicaid. Must agree to accept assignment under Medicare for all services for which payment may be made under Part B of Title XVIII and enter into an appropriate agreement with the state agency that administers the state plan for medical assistance under Title XIX to provide service to individuals entitled to medical assistance under the plan. Must pay the amount specified in their IHCPPRF Program contract default provision if they fail to complete their service obligation for any reason.

Interested Health Care Professionals meeting the requirements should: locate and secure a position at a suitable practice site (the ISDH maintains the list of HPSA locations); obtain an application from the ISDH; and submit the application and relevant documentation to the ISDH. Practice Site Requirements: Practice sites must be: Y Public or private not-for-profit entities located in a federally designated medical and/or dental HPSA. Y Committed to employing health care professionals full-time for a minimum of two (2) consecutive years (and up to 3 or 4 consecutive years if desired). Y If an applicant desires to practice in an area of need not designated as a HPSA, the applicant is required to document the need for primary health care professionals and the review committee will consider the suggested area of need as a potential practice location. (ISDH will seek HPSA designation and/or will waive the HPSA designation). Interested persons should contact: Janet Chorpenning, Project Coordinator, Indiana Health Care Professional Recruitment and Retention Fund Program, Local Liaison Office, Indiana State Department of Health, 2 North Meridian Street, Indianapolis, Indiana 46204. Telephone: 317.233.1385.

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PRIMARY CARE HEALTH PROFESSIONAL APPLICATION
INDIANA HEALTH CARE PROFESSIONAL RECRUITEMENT AND RETENTION FUND STUDENT LOAN REPAYMENT APPLICATION State Form 50775 (01-02) INDIANA STATE DEPARTMENT OF HEALTH

CONFIDENTIAL INFORMATION (per IC 4-1-8)

SECTION I - PERSONAL DATA Please type or print with ink. Applicant Name: Home Address: City Day Phone: ( ) Social Security #: Is Applicant a United States citizen? Does Applicant have a current and unrestricted Indiana license to practice his/her profession? Is Applicant free of unserved obligations for service (e.g., federal, state, local government or other entity)? Is Applicant free of judgments arising from federal debt? State: Zip Code: ) Birth Date: Yes No Evening Phone: (

Yes

No (If no, attach explanation) (If no, attach explanation)

Yes

No

Yes

No

SECTION II - HEALTH PROFESSION
M.D. ___ D.O. Family Practitioner Nurse Practitioner Certified Nurse Midwife Physician Assistant Dental Hygienist

Internist
Pediatrician Obstetrician/Gynecologist Dentist
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SECTION III - HEALTH PROFESSIONAL EDUCATION

School: City: Postgraduate Training: Board Eligible: Certificate Number: Board Certified:

Date of Graduation: State: Zip Code:

IN License Number: IN License Date:

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SECTION IV - PRACTICE SITE Note: The practice site must be in a shortage area for the profession designated by the ISDH. Applicant agrees to provide full-time primary care services at: Practice Site Name: Address: City: Practice Site Contact Person: Title: Fax No. ( ) Telephone No.: ( E-mail Address: ) County: Zip Code:

Description of Practice Site: Community or Migrant Health Center Maternal and Child Health Clinic Area Health Education Center Rural Health Clinic & Training Center Type of Practice: Public Private Not-for-profit Beginning Date of Practice: Number of Clinical Hours per Week at this Practice Location: Include a copy of the contract between yourself and your practice site. SECTION V - EDUCATIONAL DEBT Estimate of total outstanding educational debt from all lenders: Request submission of the attached Lender Disclosure Form from each loan holder. Attach a current loan statement for each loan listed. Loan statements must contain Applicant's name, account number, and the principal and payoff balances.
Private not-for-profit entities must attach a copy of their federal tax exempt letter, i.e., 501(c)(3) (This is not the date IHCPRR service will begin.)

Hospital Health Facility Nurse-managed Clinic Other:

(Attach additional copies of Section V if necessary) 4

SECTION V - EDUCATIONAL DEBT (continued) 1. Loan Holder: Loan Holder Address: City: Account Number: 2. Loan Holder: Loan Holder Address: City: Account Number: 3. Loan Holder: Loan Holder Address: City: Account Number: 4. Loan Holder: Loan Holder Address: City: Account Number: 5. Loan Holder Loan Holder Address: City: Account Number: 6. Loan Holder: Loan Holder Address: City: Account Number: State: Zip Code: Loan Balance: $ State: Zip Code: Loan Balance: $ State: Zip Code: Loan Balance: $ State: Zip Code: Loan Balance: $ State: Zip Code: Loan Balance: $ State: Zip Code: Loan Balance: $

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SECTION VI - CERTIFICATIONS (Notary Public Required)

I certify the following: During the past 12 months, I have not discriminated, nor will I in the future discriminate against any persons seeking my medical/dental or other health care services. I charge fees at the customary rate prevailing in the area in which my services are provided, except that I charge fees at a reduced rate (using a sliding fee scale), or no fee at all for services provided to anyone who does not have the insurance or income to pay the usual fee. During the past 12 months, I have accepted and will continue to accept Medicare/Medicaid assignments as full payment for my services as established in Titles XIII and XIX of the Social Security Act. All statements made in this Application are complete and accurate to the best of my knowledge. I understand that falsification will disqualify my application. I authorize representatives of the Indiana State Department of Health to contact institutions holding any of the listed educational loans, educational institutions that I attended, and employers to verify the accuracy of the information contained in this Application.

Applicant Signature (Full Legal Name) Typed or Printed Name: Social Security Number:

Date

Sworn before me this

day of

,

2001

Notary Public (full legal signature)

Affix Seal

My commission expires:

Mail your completed application to: Indiana State Department of Health Indiana Health Care Professional Recruitment and Retention Fund, 8-B 2 North Meridian Street Indianapolis, Indiana 46204

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Indiana Health Care Professional Recruitment and Retention Fund Outstanding Educational Loan Debt Information LENDER DISCLOSURE Applicant: Lender:
This form must be sent to each lending institution or agency for which you are seeking loan repayment. The lending institution should forward the completed form to our office. If the named individual's application is approved, the requested information will be used to arrange third-party pre-payment of a portion or all of the applicant's debt.

Applicant's name as it appears on loan: Original lending institution, federal or state program, please provide:
Full Name of Institution or Program Contact Person Telephone Number

Street Address

City

State

Zip Code

$
Loan ID Number Original Loan Amount Date of Original Loan

$
Grace Period/Forbearance Dates Current Balance Date of Balance

%
Interest Rate Simple or Compound

If interest rate is variable, explain terms: Purpose of loan as indicated on the application:

Certification by Applicant Borrower:
I hereby authorize the government or financial institution named above to release information to the Indiana Health Care Professional Recruitment and Retention Fund for the purpose of repayment of outstanding health care professional education debt. I also certify the accuracy of the enclosed information and apply to enter into an agreement with the INDIANA HEALTH CARE PROFESSIONAL RECRUITMENT AND RETENTION FUND for repayment of all or the appropriate portion of the educational loan listed above, incurred solely to finance undergraduate, graduate, or health care professional education (not including residency). Full Legal Signature: Date:

Certification by Authorized Agent of Lending Institution:
The undersigned states that, to the best of his or her knowledge, the loan identified above is a bona fide, legally enforceable, commercial, state, or government educational loan, made for the purpose of meeting the borrower's costs of attaining health care professional education. Print/Type Name of Authorized Agent Official Signature: Title

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