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 R9-15-302 - Initial Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. To apply
				to participate in the Behavioral Health Care Provider Loan Repayment Program,
				an applicant who has not previously participated in the Behavioral Health Care
				Provider Loan Repayment Program shall submit an initial application in
				subsection (B) to the Department by March 1 of each year.
B. An applicant applying to participate in
				the Behavioral Health Care Provider Loan Repayment Program shall submit to the
				Department:
1. The following information in a
				Department-provided format:
a. The applicant's
				name, home address, telephone number, e-mail address, Social Security number,
				and date of birth;
b. The name of
				each service site where the applicant provides behavioral health services and
				will continue to provide behavioral health services while participating in the
				Behavioral Health Care Provider Loan Repayment Program;
c. If applicable, the type of license or
				certification held by the applicant, including, if applicable, the applicant's
				National Provider Identifier (NPI) number;
d. The type of behavioral health specialty or
				subspecialty, if applicable;
e.
				Whether the applicant:
i. Provides behavioral
				health services full-time;
ii. Is
				an Arizona resident;
iii. Has any
				health professional service obligation;
iv. Has defaulted in a health professional
				service obligation and, if so, a description of the circumstances of the
				default;
v. Has experience
				providing behavioral health services to a medically underserved population;
				and
vi. Agrees to allow the
				Department to submit supplemental requests for additional information or
				documentation in
				R9-15-306;
f. For each qualifying educational loan:
i. The lender's name, street address, e-mail
				address, and telephone number;
ii.
				The address where the behavioral health 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
				behavioral health loan repayment funds the applicant establishes for a lender
				if more than one lender is receiving behavioral health loan repayment
				funds;
g. An attestation
				that:
i. The Department is authorized to
				verify all information provided in the initial application;
ii. The applicant is applying to participate
				in the Behavioral Health Care Provider Loan Repayment Program for two years
				with the State of Arizona for loan repayment of all or part of qualifying
				educational loans identified according to subsection (B)(1)(f);
iii. The qualifying educational loans
				identified according to subsection (B)(1)(f) were for the costs of health
				professional education, including reasonable educational expenses and
				reasonable living expenses, and do not reflect a loan for other purposes;
				and
iv. The information and
				documentation submitted is true and accurate;
h. Whether the applicant is delinquent on:
i. State taxes,
ii. Court-ordered child support, or
iii. A federal income tax
				liability,
i. 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
j. The applicant's signature and date of
				signature;