Arizona Administrative Code (Last Updated: November 17, 2016) |
Title 9. HEALTH SERVICES |
Chapter 15. DEPARTMENT OF HEALTH SERVICES LOAN REPAYMENT |
Article 2. PRIMARY CARE PROVIDER LOAN |
Section R9-15-212. Reapplication
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A. If the information provided in the original service site applica- tion is still accurate, and the information provided in the origi- nal primary care provider application, other than loan balances and requested repayment amounts, is still accurate, a primary care provider may reapply by submitting a completed reappli- cation form supplied by the Department. A completed reappli- cation form shall include the following:
1. The following information about the primary care pro- vider:
a. Full name,
b. Social security number,
c. Date of birth,
d. Home address,
e. Home and alternate telephone numbers,
f. Work address, and
g. Work telephone number;
2. The current balance of and repayment amount requested for each loan listed in the original primary care provider application;
3. The following statements:
a. That the information provided in the original pri- mary care provider application, other than loan bal- ances and requested repayment amounts, is still accurate;
b. That the primary care provider is reapplying to enter into a contract with the State of Arizona for repay- ment of all or part of the educational loans listed in the original primary care provider application;
c. That the Department is authorized to verify all infor- mation provided in the original primary care pro- vider application and the current balance of each loan;
d. That the loans listed in the original primary care pro- vider application were incurred solely for the costs of the primary care provider’s health professional education, including reasonable educational expenses and reasonable living expenses, and do not reflect loans for other purposes;
e. That each government or financial institution named as a lender in the original primary care provider application is authorized to release to the Depart- ment information about the loan received by the pri- mary care provider; and
f. That the primary care provider understands that the primary care provider could be fined or imprisoned for:
i. Making a false statement, misrepresentation, or
material omission in the application;
ii. Fraudulently obtaining repayment for a loan; or
iii. Committing any other illegal action in connec- tion with the PCPLRP;
4. The notarized signature of the primary care provider cer- tifying that the statements listed in subsection (A)(3) are true;
5. The full name and title of the individual in the senior leadership position at the service site;
6. A statement that the information on the original service site application is still accurate; and
7. The notarized signature of the individual in the senior leadership position at the service site certifying that the statement in subsection (A)(6) is true.
B. If the original service site application is no longer accurate, or the original primary care provider application contains inaccu- rate information other than loan balances and requested repay- ment amounts, a primary care provider may reapply only by submitting the documents and information required by R9-15- 209(A) and R9-15-210(A) and (B).
Historical Note
Repealed effective February 7, 1995 (Supp. 95-1). New Section made by final rulemaking at 7 A.A.R. 2823, effective August 9, 2001 (Supp. 01-2).