Form 0127-6 NHSC Self-Certification

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM
SELF-CERTIFICATION FORM
Purpose: Provides for self-certification of specific eligibility and other criteria for applicants to the National Health Service Corps (NHSC) Loan
Repayment Program (LRP) and reduces the response and collection burden previously approved under OMB 0915-0127, Expiration 2FWREHU 31,
2010.
Applicant Name: _______________________________________________________________________
(Print First, Middle Initial, Last Name)
Discipline: _________________________ Specialty (if applicable): _________________________

Directions: Applicants are to certify by initialing each statement below that is applicable to them and that the statement
is true.
____ Physicians: I certify that I am certified in a primary care specialty from a specialty board approved by the American Board of Medical
Specialties or the American Osteopathic Association or completed a residency program in a primary care specialty that is approved by the
Accreditation Council for Graduate Medical Education or the American Osteopathic Association and have a current, full, permanent and
unencumbered health professional license from the State in which I intend to practice as a NHSC LRP.
____ Primary Care Physicians Assistants: I certify that I have a certificate of completion or an associate, bachelor’s or master's degree from a
physician assistant educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant at a college,
university or educational institution that is accredited by a U.S. Department of Education nationally recognized regional or State institutional
accrediting agency, National certification by the National Commission on Certification of Physician Assistants, and have a current full, permanent,
unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
____ Nurse Practitioners: I certify that I have a master’s degree or post-master’s certificate, or doctoral degree from a school accredited by the
National League for Nursing Accrediting Commission or the Collegiate Nursing Education, and am certified by the American Nurses Credentialing
Center, the American Academy of Nurse Practitioners, the Pediatric Nursing Certification Board, or the National Certification Corporation, and have
a current full, permanent, unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC
LRP.
_____ Certified Nurse-Midwives: I certify that I have a master’s degree or post-baccalaureate certificate from a school accredited by the
American College of Nurse-Midwives, and am certified by the American Midwifery Certification Board, and have a current full, permanent,
unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
_____ Dentists: I certify that I have completed a D.D.S. or D.M.D from a program that is accredited by the ADA and CODA, and have a current
full, permanent, unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
_____ Pediatric Dentists: : I certify that I have completed a D.D.S. or D.M.D from a program that is accredited by the ADA and CODA, and have
completed a 2-year training program in the specialty of pediatric dentistry that is accredited by the ADA and CODA, and have a current full,
permanent, unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
_____ Registered Dental Hygienists (RDHs): I certify that I have a bachelor’s degree in dental hygiene or graduated from a 2-year dental
hygiene training program accredited by the ADA and CODA, and have a least one year of experience as a licensed dental hygienist, and have
successfully passed the National Board Dental Hygiene Examination, and have a current full, permanent, unencumbered, health professional
license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
_____ Health Service Psychologists (HSP): I certify that I have a doctoral degree directly related to clinical or counseling psychology from a
school accredited by the APA and COA, completed a minimum of one year of post-graduate supervised clinical experience, successfully passed
the Examination for Professional Practice of Psychology, can practice independently and unsupervised as an HSP, and have a current full,
permanent, unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP.
_____ Licensed Clinical Social Workers: I certify that I have a master’s or doctoral degree in social work from a school accredited by the
Council on Social Work Education, and successfully passed the Association of Social Work Boards (ASWB) Clinical or Advanced Generalist
licensing exam prior to July 1, 1998, or the ASWB Clinical licensing exam on or after July 1, 1998, can practice independently and unsupervised,
and have a current full, permanent, unencumbered, health professional license, certificate, or registration in the State in which I intend to practice
as a NHSC LRP.
_____ Psychiatric Nurse Specialists who have a master’s degree or higher in nursing from a program accredited by the NLNAC or
CCNE with a specialization in psychiatric/mental health but are not certified as a clinical specialist, and 2-years of post-graduate
supervised clinical experience, or have a bachelor’s or higher in nursing from a program accredited by NLNAC or CCNE, and certified as a
Psychiatric and Mental Health Nurse, Clinical Specialist in Adult and Mental Health Nursing, or Clinical Specialist in Child and Adolescent
Psychiatric, and Mental Health Nursing and, have a current full, permanent, unencumbered, health professional license, certificate, or registration
in the State in which I intend to practice as a NHSC LRP.

NHSC LRP Forms

C8

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

_____ Marriage & Family Therapists (MFTs): I certify that I have a master’s or doctoral degree in marriage and family therapy from a program
accredited by the AAMFT, COAMFTE or have a graduate degree in another mental health field and completed a COAMFTE accredited postgraduate degree clinical training program in marriage and family therapy, and have at least 2-years of post-graduate supervised clinical
experience in practice as a marital and family therapist or am a clinical member of the AAMFT , and have a current full, permanent,
unencumbered, health professional license, certificate, or registration in the State in which I intend to practice as a NHSC LRP and can practice
independently and unsupervised as an MFT.
_____ MFTs Without a Liscense: I certify that licensure as an MFT is not available in the State in which I intend to practice under the NHSC
LRP, and that I have a current, full, permanent, unencumbered, unrestricted health professional license, certificate or registration (whichever is
applicable) to practice independently and unsupervised as a MFT in a State.
_____ Licensed Professional Counselors (LPCs): I certify that I have a master’s degree or higher regarding counseling from a school
accredited by the U.S. Department of Education nationally recognized regional or State institutional accrediting agency, and have at least 2-years
of post-graduate supervised counseling experience, and am certified as a National Certified Counselor or a Certified Clinical Mental Health
Counselor by the National Board for Certified Counselors, and have a current full, permanent, unencumbered, health professional license,
certificate, or registration in the State in which I intend to practice as a NHSC LRP and can practice independently and unsupervised as a LPC.
.
_____ LPCs: I certify that licensure as an LPC is not available in the State in which I intend to practice under the NHSC LRP, and that I have a
current, full, permanent, unencumbered, unrestricted health professional license, certificate or registration (whichever is applicable) to practice
independently and unsupervised as an LPC in a State.
_____ Providers of Geriatrics Services: I certify that I have completed discipline-specific advanced training in geriatrics (residency, fellowship,
certification, etc.).
_____ Reservists: I certify that I am a member of a Reserve Component of the Armed Forces or National Guard.

I hereby certify that the statements initialed above are true, complete and accurate to the best of my knowledge and belief and do not omit any
material fact. I understand that the information given may be investigated and that any knowingly or willfully false representation, or concealment, of
a material fact is sufficient cause for rejection of this application, or if awarded loan repayment, that I am liable for the return of all awarded funds
and, further, that any such false statement or concealment may be punished as a felony under 18 U.S.C. 1001 and subject me to civil penalties
under the Program Fraud Civil Penalties Act of 1986.

________________________________________
Applicant Signature

NHSC LRP Forms

C9

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