Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 15 - DEPARTMENT OF HEALTH SERVICES LOAN REPAYMENT › Article 2 - PRIMARY CARE PROVIDER LOAN REPAYMENT PROGRAM › Section R9-15-202 - Initial Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. Except
				as provided in
				R9-15-203(A), to
				apply to participate in the Primary Care Provider Loan Repayment Program or
				Rural Health Care Provider Loan Repayment Program, a primary care provider who
				has not previously participated in the Primary Care Provider Loan Repayment
				Program or Rural Health Care Provider Loan Repayment Program shall submit an
				initial application to the Department by June 1 of each year.
B. A primary care provider applying to participate in
				the Primary Care Provider Loan Repayment Program or Rural Health Care Provider
				Loan Repayment Program shall submit to the Department an initial application
				containing:
1. The following information in a
				Department-provided format:
a. The primary
				care provider's:
i. Name, home address,
				telephone number, and e-mail address;
ii. Social Security number; and
iii. Date of birth;
b. The name, street address, e-mail address,
				and telephone number of the employer or prospective employer where the primary
				care provider provides or will provide primary care services while
				participating in the Primary Care Provider Loan Repayment Program or Rural
				Private Primary Care Provider Loan Repayment Program, including the dates that
				the primary care provider is expected to start and end providing primary care
				services;
c. The name, street
				address, and telephone number for each place of employment with a health
				professional or a health care institution, including a name, title, e-mail
				address, and telephone number of a contact individual for the place of
				employment;
d. Type of license and,
				if applicable, certification held by the primary care provider;
e. Type of medical, dental, or behavioral
				health specialty or subspecialty, if applicable;
f. If an advanced practice provider, a
				behavioral health care provider, or a pharmacist, whether the primary care
				provider holds national certification;
g. Whether the primary care provider will
				provide primary care services full-time or half-time;
h. Whether the primary care provider is an
				Arizona resident;
i. Whether the
				primary care provider has any health professional service obligation;
j. Whether the primary care provider has
				defaulted in a health professional service obligation and, if so, a description
				of the circumstances of the default;
k. Whether the primary care provider is
				subject to a judgment lien for a debt to a federal agency and, if so, a
				description of the circumstances of the default;
l. If applying to participate in the Primary
				Care Provider Loan Repayment Program, whether the primary care provider:
i. Has defaulted on:
(1) A Federal income tax liability,
(2) Any federally-guaranteed or insured
				student loan or home mortgage loan,
(3) A Federal Health Education Assistance
				Loan,
(4) A Federal Nursing Student
				Loan, or
(5) A Federal Housing
				Authority Loan; or
ii.
				Is delinquent on:
(1) A payment for
				court-ordered child support, or
(2)
				A payment for state taxes; or
m. If applying to participate in the Rural
				Private Primary Care Provider Loan Repayment Program, whether the primary care
				provider is delinquent on payment for:
i.
				State taxes, or
ii. Court-ordered
				child support;
n.
				Whether the primary care provider has experience providing primary care
				services to a medically underserved population;
o. Whether the primary care provider is
				providing services at a critical access hospital and primary care services at a
				service site according to
				R9-15-201(A)(1)(g);
p. Whether the primary care
				provider agrees to allow the Department to submit supplemental requests for
				additional information or documentation in
				R9-15-205;
q. An attestation that:
i. The Department is authorized to verify all
				information provided in the initial application;
ii. The primary care provider is applying to
				participate in the Primary Care Provider Loan Repayment Program or Rural
				Private Primary Care Provider Loan Repayment Program, as applicable, for two
				years with the State of Arizona for loan repayment of all or part of qualifying
				educational loans identified in the initial application;
iii. The qualifying educational loans
				identified in the initial application 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;
iv. The primary care provider will charge
				fees for primary care services according to the sliding-fee schedule in
				R9-15-201 (A)(1)(f); and
v. The information and documentation
				submitted as part of the initial application is true and accurate;
				and
r. The primary care
				provider's signature and date of signature.