Section R9-15-310. Primary Care Provider Application

A.       To apply for loan repayment, a primary care provider shall submit to the Department the following documents:

1.        A completed primary care provider application on a form provided by the Department, including the information described in subsection (B);

2.        A copy of the primary care provider’s social security card;

3.        A copy of one of the following issued to the primary care provider:

a.        Birth certificate,

b.        United States passport, or

c.        Naturalization papers;

4.        A copy of the loan documents for each qualifying loan for which repayment is requested;

5.        Documentation showing that the primary care provider has completed the final year of a course of study or pro- gram approved by an accrediting agency recognized by the United States Department of Education or the Council for Higher Education Accreditation for higher education in a health profession licensed under A.R.S. Title 32;

6.        Documentation showing that the primary care provider holds a current Arizona license or certificate in good standing in a health profession licensed under A.R.S. Title 32;

7.        If a physician, documentation showing that the primary care provider has completed a professional residency pro- gram and is either board certified or eligible to sit for the certifying examination in:

a.        Family or general practice,

b.        Pediatrics,

c.        Obstetrics, or

d.        Internal medicine;

8.        If the primary care provider is not a sole practitioner:

a.        A copy of the contract signed by both the individual in the senior leadership position at the service site and the primary care provider evidencing current or prospective employment with the service site, which may include a provision that the primary care pro- vider may or shall be released from the contract if not selected for a loan repayment award; or

b.        A copy of the letter of intent signed by the individual in the senior leadership position at the service site indicating an intent to hire the primary care pro- vider;

9.        Documentation  showing  that   any  other obligation  for

health professional service owed under a contract with a federal, state, or local government or another entity will be satisfied before beginning a period of service under the RPPCPLRP;

10.     A completed service site application; and

11.     A copy of the primary care provider’s curriculum vitae.

B.       A completed primary care provider  application 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.        Citizenship;

e.        Ethnicity;

f.         Gender;

g.        Home address;

h.        Home and alternate telephone numbers;

i.         Work address;

j.         Work telephone number;

k.        Whether the primary care provider is:

i.         A physician,

ii.        A physician assistant,

iii.      A registered nurse practitioner,

iv.      A nurse midwife, or

v.        A dentist;

l.         Whether the primary care provider specializes in:

i.         Family or general practice,

ii.        Pediatrics,

iii.      Obstetrics, or

iv.      Internal medicine;

m.      The primary care provider’s subspecialty, if any;

n.        Whether the primary care provider is fluent in:

i.         Spanish;

ii.        A Native American language, which shall be identified; or

iii.      Another non-English language, which shall be identified;

o.        The method by which the primary  care provider learned of the RPPCPLRP;

p.        The  degrees  held  by  the  primary   care  provider, including majors or fields of study;

q.        Whether the primary care provider has a prior or existing health professional service obligation and the following information about each prior or exist- ing service obligation:

i.         The name and address of the program,

ii.        The name and telephone number of an individ- ual with the program who may be contacted for further information, and

iii.      The terms of the obligation;

r.         Whether the primary care provider is in default of a health professional service obligation described under subsection (B)(1)(q) and a description of the circumstances of default, if any; and

s.        Whether any of the primary care provider’s property is subject to a judgment lien for a debt to the United States;

2.        The  following   information  about  each   undergraduate

school that the primary care provider attended:

a.        Name;

b.        Address;

c.        Month and year that attendance commenced;

d.        Month  and  year  of  graduation  or  termination  of attendance;

e.        Degree obtained by the primary care provider; and

f.         The following information about one reference at the school:

i.         Full name,

ii.        Title, and

iii.      Telephone number;

3.        The following information about each graduate school that the primary care provider attended:

a.        Name;

b.        Address;

c.        Month and year that attendance commenced;

d.        Month  and  year  of  graduation  or  termination  of attendance;

e.        Degree obtained by the primary care provider; and

f.         The following information about one reference at the school:

i.         Full name,

ii.        Title, and

iii.      Telephone number;

4.        The following information about each institution where the primary care provider commenced or completed an internship:

a.        Name;

b.        Address;

c.        Month and year that the internship commenced;

d.        Month and year of graduation or termination of the internship;

e.        The following information about one reference at the institution:

i.         Full name,

ii.        Title, and

iii.      Telephone number, and

f.         The name and address of the affiliated university or health professional program;

5.        The following information about each institution where

the primary care provider commenced or completed a res- idency:

a.        Name;

b.        Address;

c.        Month and year that the residency commenced;

d.        Month and year of graduation or termination of the residency;

e.        The following information about one reference at the institution:

i.         Full name,

ii.        Title, and

iii.      Telephone number; and

f.         The name and address of the affiliated university or health professional program;

6.        The following information about each license held by the

primary care provider:

a.        Type of license,

b.        Issuing state,

c.        License number,

d.        Term of the license, and

e.        A description of any license restrictions;

7.        The following information about each certification held by the primary care provider:

a.        Type of certification,

b.        Issuing state,

c.        Term of the certification, and

d.        A description of any certification restrictions;

8.        The following information about each location where the primary care provider has practiced since completing health professional training:

a.        Name;

b.        Address; and

c.        The following information about the individual in the senior leadership position at the location:

i.         Full name,

ii.        Title, and

iii.      Telephone number;

9.        The following information about the service site:

a.        Name;

b.        Address;

c.        Telephone number; and

d.        If the primary care provider is not a sole practitioner, name of the individual in the senior leadership posi- tion at the service site;

10.     If the primary care provider is not a sole practitioner, the following information about the prospective employer, if different from the service site:

a.        Name,

b.        Address, and

c.        Telephone number;

11.     The dates on which service under the contract is to com- mence and end;

12.     The following information about each of three profes- sional references not provided elsewhere in the applica- tion for the primary care provider:

a.        Full name,

b.        Title,

c.        Address, and

d.        Telephone number;

13.     The following information about each loan for which repayment is sought:

a.        Lender name;

b.        Lender address;

c.        Lender telephone number;

d.        Loan identification number;

e.        Primary care provider name as it appears on  the loan;

f.         Original amount of the loan;

g.        Current balance of the loan, including the date pro- vided;

h.        Interest rate on the loan;

i.         Whether it is simple interest and an explanation if it is not simple interest;

j.         Purpose for the loan as indicated on the loan applica- tion; and

k.        The month and year of the beginning and end of the academic period covered by the loan;

14.     The following statements:

a.        That the information provided in the application is accurate;

b.        That the primary care provider is applying to enter into a contract with the State of Arizona for repay- ment of all or part of the educational loans listed in the application;

c.        That the Department is authorized to verify all infor- mation provided in the application;

d.        That the loans listed in the application were incurred solely for the costs of health professional education, including reasonable educational expenses and rea- sonable living expenses, and do not reflect loans for other purposes;

e.        That each government or financial institution named as a lender in the application is authorized to release to the Department information about the loan received by the primary 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 RPPCPLRP;

15.     The notarized signature of the primary care provider cer- tifying that the statements listed in subsection (B)(14) are true; and

16.     For each loan for which repayment is sought, the nota- rized signature of an individual authorized to sign for the lender certifying that the loan from that lender is a bona fide and legally enforceable commercial or government loan made to meet the costs of the primary care pro- vider’s health professional education.

C.       A primary care provider shall execute any document necessary for the Department to access records and acquire information necessary to verify information provided by the primary care provider.

D.       The Department shall verify all loan information with each lender. The Department may verify any other information pro- vided by the primary care provider.

Historical Note

New Section made by final rulemaking at 7 A.A.R. 2823, effective August 9, 2001 (Supp. 01-2).