Delta Doctors Program – J-1 Visa Waiver Checklist 

Effective: October 15, 2022

Delta Doctors Program

J-1 Visa Waiver Application Checklist

Date Received: Physician’s Name:

Reviewer: DOS Case Number:

Review Start Date: DOB:

Date Sent to DOS: Country of Birth:

DRA’s Letter for File: Last Permanent 

Residence of:

Shipping Label for File: Specialty:

Date Sent to Attorney: Current Address:

Recorded in Database: Phone Number:

Reviewer Notes: Email:

HPSA number:

MUA number:

Term:

Work site:

*Provide additional 

worksites with 

HPSA/MUA number(s) 

on separate page.

County/Parish:

Attorney: Employer name:

Firm name: Employer contact name:
Delta Doctors Program – J-1 Visa Waiver Checklist 

Effective: October 15, 2022

Attorney address: Employer address:

Attorney phone number: Employer phone number:

Attorney fax number: Employer fax number:

Attorney email: Employer email:
Delta Doctors Program – J-1 Visa Waiver Checklist 

Effective: October 15, 2022

Delta Doctors Program

J-1 Visa Waiver Application Checklist

Two packets are required for submission to the U.S. Department of State and to the 

Delta Regional Authority.

Packet 1: Must contain Items 1 through 10.

Packet 2: Must contain Items 1 through 22.

Checklist

For DRA use 

only.

Item 

# Required Documentation/Information Attorney Checklist

1 Form G-28 – Notice of Entry of Appearance as Attorney or Accredited 

Represenative

2 Cover letter from employer/facility

NIW support?

HPSA number:

MUA number:

FIPS number:

Physician information

Medicare/Medicaid/Indigent pop. (3-year data)

Patient-to-Physician ratio:

3 DS-3035 and Supplementary Applicant Information Pages

Statement of Reason?

Third Party Barcode?

Waiver Division Barcode?
Delta Doctors Program – J-1 Visa Waiver Checklist 

Effective: October 15, 2022

Case number verified?

2 copies?

4 CV with social Security number

5 DOS exchange visitor attestation form

Signed/Dated by physician; Notarized?

6 Copy of executed contract

Signed/Dated by physician and employer

3-year service? 5-year service (NIW)?

No non-compete clause

160 hours/month of primary/specialty medical care

Service to Medicare/Medicaid/Indigent population

Base salary:

Name and address of each facility:

7 Proof of HPSA/MUA status

Status verified?

8 IAP-66/DS-2019

Verify from entry to present

9 Copy of I-94

10 Recruiting documentation

Recruitment overview sheet

National/State/State Medical Schools/Other

11 Letter of opinion from legal representation

Requesting NIW?

12 DRA J-1 program guidelines
Delta Doctors Program – J-1 Visa Waiver Checklist 

Effective: October 15, 2022

Signed/Dated by physician and employer

13 DRA affidavit and agreement

Signed/Dated by physician; Notarized?

All pages included?

14 Proof of prevailing wage data

Level I:

Level II:

15 Letters of community support

Two (2) letters from local, unaffiliatd physicians; one of which 

must be a local, unaffiliated primary care physician.

One (1) local elected official

16 Letters of recommendation

17 Copy of diploma(s), board certification(s), USLME scores, etc..

State medical license or application for license

18 Proof of existence for each facility

19 Copy of posted public notice of sliding fee payment for each facility

20 List of primary care or specialty physicians in county/parish

21 Passport(s)

22 Physician statement

NIW statement (if applicable)