Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 15 - DEPARTMENT OF HEALTH SERVICES LOAN REPAYMENT › Article 3 - BEHAVIORAL HEALTH CARE PROVIDER LOAN REPAYMENT PROGRAM › Section R9-15-303 - Renewal Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				applicant who is expected to complete the initial two years of participation in
				the Behavioral Health Care Provider Loan Repayment Program in the 12 months
				after January 15 of each year, and whose service site is the Arizona State
				Hospital or has a HPSA score of 14 or more may request to continue
				participation by submitting to the Department a renewal application in
				subsection (B) by January 15 of the same year.
B. An applicant applying to renew
				participation in the Behavioral Health Care Provider Loan Repayment Program for
				an additional year shall submit to the Department:
1. The following information in a
				Department-provided format:
a. The
				applicant's name, home address, telephone number, and e-mail address;
b. The existing behavioral health loan
				repayment contract number;
c. The
				name of each service site where the applicant provides behavioral health
				services, including street address, telephone number, e-mail address, and fax
				number;
d. Except for a request for
				a change made according to
				R9-15-106, a list of any changes
				that may affect the applicant's health service priority in
				R9-15-306;
e. For each lender receiving loan repayment
				funds specified according to
				R9-15-302(B)(1)(f)
				or R9-15-106:
i. The lender's name, street address, e-mail
				address, and telephone number;
ii.
				The address where the loan repayment funds are sent;
iii. The loan identification
				number;
iv. If different from the
				information specified according to
				R9-15-302(B)(1)(f)
				or R9-15-106, the percentage of the
				loan repayment funds that the applicant wants the lender to receive;
v. Current loan balance, including date
				provided; and
vi. Whether the
				applicant requests to continue loan repayment to the lender;
f. If the applicant wants to add a
				qualifying educational loan:
i. The lender's
				name, street address, e-mail address, and telephone number;
ii. The address where the loan repayment
				funds are sent;
iii. The loan
				identification number;
iv. The
				original date of the loan;
v. The
				applicant's name as it appears on the loan contract;
vi. The original loan amount;
vii. The current balance of the loan,
				including the date provided;
viii.
				The interest rate on the loan;
ix.
				The purpose for the loan;
x. The
				month and year of the start and the end of the academic period covered by the
				loan; and
xi. The percentage of the
				loan repayment funds that the applicant wants the lender to receive;
g. Whether the applicant agrees to
				allow the Department to submit supplemental requests for additional information
				or documentation in
				R9-15-305;
h. The applicant's attestation that:
i. Except for the circumstances listed in
				subsection (C)(1)(d), the information specified according to
				R9-15-302(B),
				other than loan balances and requested repayment amounts, is still
				current;
ii. The Department is
				authorized to verify all information provided in the renewal
				application;
iii. The applicant is
				applying to participate in the Behavioral Health Care Provider Loan Repayment
				Program for an additional year for loan repayment of all or part of the
				qualifying educational loans identified according to subsection (B)(1)(e) or
				(f); and
iv. The information and
				documentation submitted as part of the renewal application is true and
				accurate;
i. Whether the
				applicant is delinquent on payment of:
i.
				State taxes,
ii. Court-ordered
				child support, or
iii. A federal
				income tax liability;
j.
				Whether the applicant has defaulted on:
i.
				Any federally-guaranteed or insured student loan or home mortgage
				loan,
ii. A Federal Health
				Education Assistance Loan,
iii. A
				Federal Nursing Student Loan, or
iv. A Federal Housing Authority Loan;
				and
k. The applicant's
				signature and date of signature;