Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 15 - DEPARTMENT OF HEALTH SERVICES LOAN REPAYMENT › Article 2 - PRIMARY CARE PROVIDER LOAN REPAYMENT PROGRAM › Section R9-15-204 - Supplemental Initial Application

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				If a primary care provider submits an initial application to the Department
				according to R9-15-202 and is not approved to participate in the Primary Care
				Provider Loan Repayment Program or Rural Private Primary Care Provider Loan
				Repayment Program, as applicable, during the initial application allocation
				process, the primary care provider may reapply during the October allocation
				process by submitting a supplemental initial application according to
				subsection (B) by October 1 of the same calendar year.
B. A primary care provider reapplying for an
				October allocation process according to
				R9-15-202(A) shall
				submit a supplemental initial application in a Department-provided format to
				the Department that contains:
1. The primary
				care provider's name, home address, telephone number, and e-mail
				address;
2. The primary care
				provider's attestation that:
a. The
				Department is authorized to verify all information provided in the supplemental
				initial application;
b. The primary
				care provider is applying to participate in either the Primary Care Provider
				Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment
				Program for two years for loan repayment of all or part of qualifying
				educational loans identified in the initial application;
c. The initial application submitted prior to
				the October allocation process of the same calendar year is still accurate,
				except for loan or lender information;
d. The primary care provider will charge fees
				for primary care services according to
				R9-15-201(A)(2)(d);
e. Whether the primary care provider agrees
				to allow the Department to submit supplemental requests for additional
				information or documentation in
				R9-15-205;
f. The information and documentation
				submitted as part of the supplemental initial application is true and accurate;
				and
g. The primary care provider's
				signature and date of signature;
3. For each primary care provider lender, the
				following:
a. The lender's name, street
				address, e-mail address, and telephone number;
b. The loan identification number;
				and
c. The loan balance including
				principal and interest;
4. An attestation from the designee of the
				governing authority of the service site that includes:
a. Name, street address, telephone number,
				e-mail address, and fax number of the service site;
b. Whether the service site:
i. Complies with the requirements in A.R.S.
				§
												36-2172(B)(2),
				or
ii. Is a private practice
				service site in A.R.S. §
												36-2174;
c. The service site provider agrees to comply
				with the requirements in
				R9-15-201, including agreeing to
				notify the Department when the employment status of the primary care provider
				changes;
d. Whether the primary
				care provider is providing primary care services full-time or
				half-time;
e. The dates that the
				primary care provider is expected to start and end providing primary care
				services;
f. The name, title,
				e-mail address, and telephone number of a contact individual for the service
				site;
g. The information submitted
				as part of the supplemental initial application is true and accurate;
				and
h. the signature of the
				designee of the governing authority of the service site and date of
				signature;
5. If the
				primary care provider's employer is not the governing authority of the service
				site identified in subsection (B)(4), an attestation from the employer that
				includes:
a. The name, title, e-mail address,
				and telephone number of a contact individual for the employer;
b. Whether the employer:
i. Complies with the requirements in A.R.S.
				§
												36-2172(B)(2),
				or
ii. Is a private practice
				service site according to A.R.S. §
												36-2174;
c. Whether the primary care provider is
				providing primary care services full-time or half-time;
d. The dates that the primary care provider
				is expected to start and end providing primary care services;
e. An attestation that the employer will
				comply with the requirements in
				R9-15-201, including agreeing to
				notify the Department when the employment status of the primary care provider
				changes;
f. The information
				submitted as part of the supplemental initial application is true and accurate;
				and
g. The employer's signature and
				date of signature;
6. A
				copy of the most recent billing statement for the loans listed on the initial
				application; and
7. Documentation
				of a service site's HPSA designation and HPSA score dated within 30 calendar
				days before the supplemental initial application submission date.