Form 0230 site application

N H S C U S E O N L Y

UDS # ________________

HPSA TYPE: _Primary Care_____

HPSA ID #: __________________

HPSA TYPE: _Dental_____

HPSA ID #: __________________

HPSA TYPE: _Mental Health____

HPSA ID #: __________________

OMB Number 0915-0230/Exp. 08/31/2008

National Health Service Corps (NHSC)

Multi-Year Recruitment & Retention Assistance Application

Please be sure to read all instructions carefully.

1. PRACTICE INFORMATION This information is only for the clinical practice site where the NHSC clinician(s) will serve. Organizations with more than one site (i.e. satellites) must submit an NHSC R&R application for each clinical practice site where the NHSC obligated clinician will practice. Please note, each clinical practice site must obtain written approval from the NHSC in order for NHSC obligated clinicians to receive service credit for time spent at all clinical practice site locations.

Please check the Health Professional Shortage Area (HPSA) type(s) you are recruiting for:

___ Primary Care ____________ HPSA ID Number _____ Score

___ Dental ____________ HPSA ID Number _____ Score

___ Mental Health ____________ HPSA ID Number _____ Score

Complete Practice Site Name: __________________________________________________________

(Where the NHSC clinician will serve their obligation)

Place an (x) to indicate clinical practice site type: ______ Primary Site ______ Satellite Site

Does the clinical practice site provide professional liability coverage, to include tail coverage? __ Yes __ No

Designated NHSC Point of Contact and Title: ________________________________________________

(Example, Dr. Jane Doe, Clinical Director)

Street Address: __________________________________________________________________________

City: ___________________ State: __________ Zip Code: ________ County: ______________________

Direct Telephone Number: _____________________________ FAX: _____________________________

E-Mail Address: ______________________________________________

Web Site Address (If Applicable): ____________________________________________

Alternate NHSC Point of Contact and Title: ____________________________________

(Example, John Doe, CFNP, Associate Clinical Director)

Street Address: __________________________________________________________________________

City: ___________________ State: __________ Zip Code: ________ County: ______________________

Direct Telephone Number: _____________________________ FAX: _____________________________

E-Mail Address: ______________________________________________

Web Site Address (If Applicable): ____________________________________________

Mailing Address for the Practice Location: Provide only if different than physical location where our NHSC obligated clinician will be providing clinical services.

Complete Organization Name: ________________________________________________________________

Street Address: ____________________________________________________________________________

City: ___________________ State: __________ Zip Code: ________ County: ______________________

2) INFORMATION ABOUT THE PRACTICE

Type of Practice: See instructions for descriptions of type of practices.

_____ Federally Qualified Health Center (FQHC) _____ Federally Qualified Health Center Look-Alike

_____ Certified Rural Health Clinic (RHC) _____ Federal Indian Health Service Site

_____ Tribally (638) Run Indian Health Service Site _____ Solo Practice/Partnership

_____ Group Practice _____ Clinic Network

_____ Managed Care _____ Hospital Affiliated Primary Care Practice

_____ State Prison _____ Federal Bureau of Prisons

_____ US Immigration, Customs & Enforcement (ICE) _____ Public Health Department

____ Private Non-Profit ____ Public ( ___Fed ___ State ___ City ___ Local) ____ Private For-Profit

__________ Urban __________ Rural

3) CONTACT INFORMATION

Parent Agency (Complete Name): ________________________________________________________

Street Address: _______________________________________________________________________

City/State/Zip Code: ____________________________________________________________________

Uniformed Data System (UDS) Number, if known: ____________________________________________

Human Resources/Recruitment Contact (If different from NHSC Point of Contact on Page 1:

MAILING ADDRESS FOR RECRUITMENT CONTACT, WHERE RESUMES AND IMPORTANT NHSC CORRESPONDENCE WILL BE SENT. IT IS CRITICAL THAT THIS INFORMATION BE ACCURATE, SINCE THIS IS WHAT WILL BE POSTED ON THE NHSC ON-LINE OPPORTUNITIES LIST AS THE PERSON TO CALL FOR SITE AND OPPORTUNITY INFORMATION

Name and Title: ________________________________________________________________________

Street Address: __________________________________________________________________________

City: ___________________ State: __________ Zip Code: ________ County: ______________________

Direct Telephone Number: _____________________________ FAX: _____________________________

E-Mail Address: ______________________________________________

4) STAFFING LEVELS

	NUMBER OF NHSC VACANCIES REQUESTED *Indicate if the position is a full FTE or % (i.e., .5, .25)	PROJECTED HIRE DATE, MONTH AND YEAR *If the position(s) have been filled with a clinician wishing to apply for NHSC Loan Repayment or an NHSC Scholar please indicate “filled” in this column.	CLINICIAN’S NAME *Indicate the clinician’s name if the vacancy has been filled with a NHSC scholar or loan repayor.	Is the clinician a COMMISSIONED OFFICER type yes or no If CO is a Ready Responder indicate as RR
PRIMARY CARE PHYSICIANS
Family Practice OB Required? Yes / No
Internal Medicine
Pediatricians
Obstetrician/Gynecologists
PRIMARY CARE NURSING/ PHYSICIAN ASSISTANTS
Family Nurse Practitioners
Adult Nurse Practitioners
Geriatric Nurse Practitioners
Pediatric Nurse Practitioners
Womens Health Nurse Practitioners
Certified-Nurse Midwives
Physician Assistants

STAFFING LEVELS CONTINUED

	NUMBER OF NHSC VACANCIES REQUESTED *Indicate if the position is a full FTE or % (i.e., .5, .25)	PROJECTED HIRE DATE, MONTH AND YEAR *If the position(s) have been filled with a clinician wishing to apply for NHSC Loan Repayment or an NHSC Scholar please indicate “filled” in this column.	CLINICIAN’S NAME *Indicate the clinician’s name if the vacancy has been filled with a NHSC scholar or loan repayor.	Is the clinician a COMMISSIONED OFFICER type yes or no If CO is a Ready Responder indicate as RR
ORAL HEALTH
Dentists
Dental Hygienists
MENTAL & BEHAVIORAL HEALTH
Psychiatrist Physician
Clinical Psychologists
Clinical Social Workers
Nurse Practitioner – PSY Specialty
Psychiatric Nurse Specialists
Licensed Professional Counselors
Marriage & Family Therapists

Filled Positions

If you are requesting to be approved as an NHSC clinical practice site for an individual already on staff or in the process of being hired, please indicate in the “projected hire date” column on the Staffing Levels Chart and provide the following details: (Note: these positions will not be posted as openings on the NHSC On-Line Opportunities List since they are “filled” vacancies.) Please be aware that an NHSC clinician can provide primary care services at a maximum of four clinical practice sites.

1. Name and Title: _________________________________________________________________

Discipline ________________________ Specialty: _______________________________

Potential NHSC Loan Repayment Program Applicant: _____ Yes _____ No

NHSC Scholar _____ Yes _____ No

NHSC Clinician transferring (Must be pre-approved by NHSC): _____ Yes _____ No

USPHS Commissioned Officer: _____ Yes _____ No _____ Rank

Ready Responder: _____ Yes _____ No _____ Rank

Reminder: NHSC obligated clinician can serve at a maximum of four NHSC approved clinical practice sites.

Clinician will work 100% of time at this practice location? _____ Yes _____ No If No, what percentage will the clinician work at this clinical practice site (indicate percentage) ______%

At what other clinical practice site(s) will clinician work:

Clinical Practice Site # 2: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/ State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 3: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 4: ________________________________________________________

Street Address: ________________________________________________________________

City/Parrish/State/ /Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Reminder: All clinical practice sites must be NHSC approved. If the clinical practice site does not have current NHSC approval, then an R&R must be submitted for review and approval.

Has an NHSC R&R Application been submitted for other site(s)? _____ Yes _____ No

Is the clinician a salaried employee? _____ Yes _____ No

Is the salary comparable to other salaries in the area for comparably trained/experienced clinicians?

_____ Yes _____ No

Is the site providing professional liability coverage, including tail coverage? _____ Yes _____ No

2) Name and Title: __________________________________________________________________

Discipline: ___________________________ Specialty: __________________ _________________

Potential NHSC Loan Repayment Program Applicant: _____ Yes _____ No

NHSC Scholar _____ Yes _____ No

NHSC Clinician transferring (Must be pre-approved by NHSC): _____ Yes _____ No

USPHS Commissioned Officer: _____ Yes _____ No _____ Rank

Ready Responder: _____ Yes _____ No _____ Rank

Clinician will work 100% of time at this practice location? _____ Yes _____ No If No, what percentage will the clinician work at this clinical practice site (indicate percentage) ______%

At what other clinical practice site(s) will clinician work:

Clinical Practice Site # 2: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/ State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 3: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 4: ________________________________________________________

Street Address: ________________________________________________________________

City/Parrish/State/ /Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

3) Name and Title: _______________________________________________ Discipline ___________

Specialty: __________________ Subspecialty: _____________________

Potential NHSC Loan Repayment Program Applicant: _____ Yes _____ No

NHSC Scholar _____ Yes _____ No

NHSC Clinician transferring (Must be pre-approved by NHSC): _____ Yes _____ No

USPHS Commissioned Officer: _____ Yes _____ No _____ Rank

Ready Responder: _____ Yes _____ No _____ Rank

Clinician will work 100% of time at this practice location? _____ Yes _____ No If No, what percentage will the clinician work at this clinical practice site (indicate percentage) ______%

At what other clinical practice site(s) will clinician work:

Clinical Practice Site # 2: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/ State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 3: ________________________________________________________

Street Address: ________________________________________________________________

City/ Parrish/State/Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Clinical Practice Site # 4: ________________________________________________________

Street Address: ________________________________________________________________

City/Parrish/State/ /Zip Code:______________________________________________________

Uniformed Data System (UDS) Number, if known: _____________________________________

Is professional liability coverage, to include tail coverage provided? __ Yes __ No

Is the clinician a salaried employee? _____ Yes _____ No

Is the salary comparable to other salaries in the area for comparably trained/experienced clinicians?

_____ Yes _____ No

Open Positions

For all open positions listed in the Staffing Level Chart (which will be posted on the NHSC On-line Opportunities List), will the clinician(s) filling the position(s) be hired as salaried employees? ______Yes ______ No

If Yes, is the salary comparable to other salaries in the area for comparably trained/ experienced clinicians?

_____ Yes _____ No

Is the site offering professional liability coverage, including tail coverage, for the open positions? ___ Yes ___ No

Please provide the above information for each specific vacancy if answers do not apply to all vacancies.

5. AGREEMENT FOR ALL PARTICIPATING NHSC SITES

__________________________________________________________________________________

(Insert Practice Site Name and Practice Site Address)

This is to certify that the above site currently meets all NHSC requirements as outlined below, and I am authorized to provide such certification for the above named site. (If you have questions regarding any of the following requirements, please see the application instructions or contact the NHSC at 1-800-221-9393 for clarification.) Any false statement(s) herein may be punished as a felony under U.S. Code, Title 18, Section 1001 and subject you to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79). Sites must meet all requirements at the time of application.

I certify that the site named above:

1. Does not discriminate in the provision of services to an individual (i) because the individual is unable to pay or because payment for those services would be made under Medicare, Medicaid or the State Children’s Health Insurance Program or (ii) based upon the individual’s race, color, sex, national origin, disability, or religion.

1. Uses a schedule of fees or payments for the site’s services that is consistent with locally prevailing rates or charges and is designed to cover the site’s reasonable cost of operation.

2. Provides health care services at no charge, or at a nominal charge, to patients whose incomes are at or below 200% of the federal poverty guidelines, which are revised annually in March. For example, the poverty level for a family of four is $18,400 (100%); thus, a 200% poverty level for this family would be $36,800. NHSC sites utilize different practices to ensure that no barriers to care exist, including establishing a schedule of discounts based on patients’ ability to pay.

3. Makes every reasonable effort to secure payment in accordance with the schedule of fees or schedule of discounts from the patient and/or any other third party.

4. Accepts assignment for Medicare beneficiaries and has entered into an appropriate agreement with the applicable State agency for Medicaid and State Children’s Health Insurance Program beneficiaries.

5. Prominently advertises a statement expressing that no one will be denied access to services due to inability to pay.

2. Ensures the site will treat patients who come from or reside in the federally-designated Health Professional Shortage Area (HPSA) where the practice is located.

3. Provides culturally appropriate ambulatory primary health, dental health, and/or mental health care services.

4. Uses a credentialing process which, at a minimum, includes reference review, licensure verification, and a query of the National Practitioner Data Bank (NPDB) of those clinicians for whom the NPDB maintains data.

5. Functions as part of a system of care which either offers or assures access to ancillary, inpatient, and specialty referrals.

6. Adheres to sound fiscal management policies and adopts clinician recruitment and retention policies to help the patient population, the site, and the community obtain maximum benefits.

7. Will not reduce the salary of NHSC clinicians because they receive benefits under the NHSC Loan Repayment or Scholarship programs.

8. Will require NHSC clinicians to maintain a full-time primary care clinical practice as defined below:

For all health professionals, except obstetrician/gynecologist (OB/GYN) physicians, family practice physicians who do OB consistently, and CNMs, at least 32 of the minimum of 40 hours per week must be spent providing clinical services. These services must be conducted during normally scheduled clinic hours in the ambulatory care setting office(s) for which the vacancy is approved. The remaining hours must be spent providing inpatient care to patients of that clinic and/or in practice-related administrative activities.

For OB/GYN physicians, family practice physicians who do OB consistently, and CNMs, at least 21 of the minimum 40 hour week must be spent providing clinical services. These services must be conducted during normally scheduled clinic hours in the ambulatory care clinic(s) for which the vacancy is approved. The remaining hours must be spent providing inpatient care to patients of that clinic and/or performing practice-related administrative activities, with administrative activities not to exceed 8 hours of the 40 hour week.

The 40 hours per week may be compressed into no less than 4 days per week, with no more than 12 hours of work performed in any 24-hour period. Time spent in "on-call" status will not count toward the 40-hour week. Hours worked in excess of 40 hours per week will not be applied to any other workweek.

NHSC clinicians can spend no more than 7 weeks (35 workdays) per year away from the practice for vacation, holidays, continuing professional education, illness, or any other reason. Absences greater than 7 weeks in an NHSC service year will extend the service commitment end date. Site must inform the NHSC when a NHSC clinician goes on extended medical leave or exceeds their 35-day allowance.

9. Supports clinicians with funding and arrangements, including clinical coverage, for their time away from the site to attend NHSC sponsored meetings and other continuing education programs.

10. Will communicate to the NHSC any change in site or clinician employment status, including moving a NHSC clinician to a satellite site for any or all of their 40 hour work week, termination, etc.

11. Maintain and make available for review by NHSC representatives all personnel and practice records associated with an NHSC clinician including documentation which contains such information that the Department may need to determine if the individual and/or site has complied with NHSC requirements.

12. Submit a Uniformed Data System (UDS) report to HRSA annually.

The signature of the Site Official below 1) certifies that the information provided in paragraphs 1-4 of this application is true and correct and 2) signifies that the above named site agrees to comply with the requirements set forth in Paragraph 5 of this application. (If you have questions regarding any of the requirements listed above, please see the application instructions or contact the NHSC at 1-800-221-9393 for clarification. Any false statement herein may be punished as a felony under U.S. Code, Title 18, Section 1001 and subject you to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79).)

Name of Site Official: _____________________________________________________________

Title of Approving Site Official: _____________________________________________________

Signature: _________________________________________________________ Date: ________

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0230. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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