Form 1 FY 2020 Combined Application Content DRAFT

The National Health Service Corps (NHSC) Loan Repayment Programs

FY 2020 Combined Application Content DRAFT

The National Health Service Corps (NHSC) Loan Repayment Program Application

OMB: 0915-0127

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0127 can be found here:

Document [pdf]

Download: pdf | pdf

Public Burden Statement: The purpose of this information collection is to obtain information
through the National Health Service Corps (NHSC) Loan Repayment Program (LRP), NHSC
Substance Use Disorder (SUD) Workforce LRP, and the NHSC Rural Community LRP applications,
which are used to assess an LRP applicant’s eligibility and qualifications for the LRP and to
obtain information for NHSC site applicants. Clinicians interested in participating in a NHSC LRP
must submit an application to the NHSC to participate in one of the NHSC programs, and health
care facilities must submit an NHSC Site Application and Site Recertification Application to
determine the eligibility of sites to participate in the NHSC as an approved service site. 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 information collection is 0915-0127 and it is valid until XX/XX/202X. This information
collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health
Service Act). Public reporting burden for this collection of information is estimated to average
0.5 hours 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 14N136B, Rockville, Maryland, 20857 or [email protected].

APPLICATION CONTENT

00 Login and Create Account Page DRAFT docx
LOAN REPAYMENT PROGRAM APPLICATION

Create an Account
Want to apply for the NHSC Loan Repayment Program, NHSC SUDWORKFORCE LRP or the NHSC
Rural Community Loan Repayment Program?
Create an NHSC LRP Application Account

Note: If you have previously registered to apply to the NHSC LRP or any other BHW program in
the current or past application cycles, or are a current NHSC Scholar, please use your existing
account information to log in.

OMB Public Burden Statement
An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a current OMB control number. The current OMB control
number for information collected through this application process is 0915-0127 and the
expiration date is 02/29/2020. Public reporting burden for this collection is estimated to
average 1.0 hour(s) per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, 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 Office, 5600 Fishers Lane, Room 10C-03, Rockville, Maryland.

Commented [HO(1]: Do we need to update this to 2021?
Commented [HM(2R1]: Has OMB date been confirmed?
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FRN pending

Questions?
For more information or questions please:





Refer to the Portal FAQ
Contact the BHW Customer Care Center at 1-800-221-9393
Use TTY for hearing impaired: 1-877-897-9910

Monday-Friday (except Federal holidays), 8:00 am to 8:00 pm ET or Contact Us.

Create My Account
* required field
This application serves three separate National Health Service Corps (NHSC) loan repayment
programs; NHSC Loan Repayment (LRP) 2-year, NHSC Substance Use Disorder (SUD)
Workforce LRP and the NHSC Rural Community LRP . Prior to creating an account, read the
2019 National Health Service Corps (NHSC) Application and Program Guidance (APG) for the
NHSC Loan Repayment Program (LRP), NHSC Rural Community LRP and the NHSC Substance
Use Disorder (SUD) Workforce LRP to determine your eligibility and to ensure you are applying
to the appropriate program.
To be eligible to participate in the NHSC Programs you must be able to verify that you are:






A U.S. Citizen or U.S. National
Trained, certified, registered or licensed in an eligible primary care or mental health
discipline
Providing clinical services at an NHSC-approved service site
Without outstanding service obligation(s)
A current, full, permanent, unencumbered, unrestricted health professional with a
license, certificate or registration in the discipline in which he/she is applying to serve

Complete the information below to register to apply. The NHSC will use the email address you
provide and verify to communicate vital time-sensitive information regarding your application.
Provide an email address that you can access from most anywhere. In many cases the
communications include requests to take an action with a rigid deadline that cannot be
extended. Missing a deadline may result in not being selected for an award.

First Name *
Last Name *
2

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Middle Initial
Title
Suffix
Email *
Confirm Email *
Create Password * Tooltip
Confirm Password *
Security Question *
Security Answer *

0-Home Page DRAFT
Loan Repayment Program Application
2020 NATIONAL HEALTH SERVICE CORP (NHSC) LOAN REPAYMENT PROGRAM (LRP) APPLICATION
Hello Test,
Thank you for registering to apply to National Health Service Corps (NHSC). The NHSC is seeking
applicants who are committed to providing primary care services to the nation's most vulnerable
populations. To qualify, for a NHSC loan repayment program award, you must meet all NHSC program
and practice requirements at the time you submit your application and before an award can be
approved. The NHSC is currently accepting applications for the following programs through April 20,
2020, 7:30 pm ET.
NHSC Programs

Years of Service

Full-time Award Amount

Half-time Award Amount

NHSC LRP (Traditional)

2-Years

$50,000.00

$25,000.00*

NHSC Substance Use Disorder
workforce LRP

3- Years

$75,000.00

$37,500.00

NHSC Rural Community LRP

3- Years

$100,000.00

$50,000.00

*NOTE: The 2-year half-time maximum NHSC Loan Repayment Program award for any fraction of service
at HPSA scores 13 and lower, is $30,000.00.

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To learn more about the 2020 National Health Service Corps (NHSC) Loan Repayment Programs, refer to
the Application and Program Guidance (APG) for the NHSC Loan Repayment Program (LRP), NHSC Rural
Community LRP and the NHSC Substance Use Disorder (SUD) Workforce LRP.

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Certain applicants may be eligible for multiple National Health Service Corps Loan Repayment programs.
The NHSC will review the information you submitted to determine your eligibility for multiple NHSC
Loan Repayment Programs. If the NHSC determines that you are eligible for an award in more than one
of the NHSC LRP programs, the NHSC will contact you to determine your preferred program. However,
the NHSC cannot guarantee that you will be offered an award under the preferred NHSC program.
Before you get started

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For your reference, review and print the Application Checklist before beginning your application. The
application checklist details the application section and supporting documents. Gather the materials in
advance to decrease your application time. Application Checklist.

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If you have technical, difficulties while completing the application please contact the Customer Care
Center from 8:00 AM to 8:00 PM ET, at 1-800-221-9393.

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information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

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1-Eligibility Page.docx DRAFT
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National Health Service Corps Eligibility
Answers to the questions below will determine your basic eligibility for a National Health
Service Corps Loan Repayment award.
* required field
1. Do you or will you have a current, full, permanent, unencumbered, and unrestricted health
professional license, certificate or registration in the discipline/specialty in the State in which
you intend to practice under the NHSC Loan Repayment Program (LRP), the NHSC Substance
Use Disorder Workforce LRP or the NHSC Rural Community LRP on or before July 18, 2019? *
Yes

2. Are you a citizen or national of the United States?
You will be asked to provide a verifying document later in the application. Valid birth
certificates, current passports or naturalization papers are accepted. *
Yes

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updated to 2020. Please update the month and day if
necessary.

3. Do you have another existing/remaining service obligation as a health professional, or any
other service obligation, to the Federal government (e.g., an active duty military obligation, an
NHSC Scholarship Program obligation or a NURSE Corps Loan Repayment Program obligation),
to a State (e.g., a State Loan Repayment Program obligation), or to any other entity (e.g., any
signed obligation that obligates you to remain employed at a certain geographical location)? *
Tooltip
Yes

4. Have you ever had a judgment lien against your property arising from a Federal debt? *
Yes

5. Have you defaulted on any Federal payment obligations, such as Health Education Assistance
Loans, Nursing Student Loans, FHA or other Federal Mortgage Loans, Federal income tax
liabilities, Federal student loans; OR, non-Federal payment obligations, such as court-ordered
child support payments? *
Yes

6. Are you currently in breach of a health professional service obligation to the Federal, State,
or Local government? *
Yes

7. Have you defaulted on a prior service obligation to a Federal, State, Local government, or
other entity? *
Yes

OMB No. 0915-0127 Expiration Date: 02/29/2020

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information has changed.
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2-Program Eligibility_Page NHSC LRP and SUD DRAFT
Program Eligibility

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The answers you provide to the questions below will determine the National Health Service Corps
(NHSC) Loan Repayment Program (LRP) you are eligible to apply for in the Application Information
Section. Prior to responding to the questions below, read the NHSC LRP Application and Program
Guidance(s) to determine the eligibility for the NHSC LRP, NHSC Substance Use Workforce (SUD) LRP and
the NHSC Rural Community LRP.

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*Required fields
*1. Are you a Dental Provider?


Yes



*2. Are you practicing as a Certified Nurse Anesthetist, Registered Nurse, Pharmacist or SUD Counselor?


Certified Registered Nurse Anesthetist



Registered Nurse



Pharmacist



SUD Counselor



None of the above

*3. Are you a SUD Counselor with masters level health profession degree?


Yes



*4. If no, do you have a masters level SUD Certification? *


Yes



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3-Application Information Page. DRAFT
Application Information
You are eligible to submit an application for a loan repayment award under the program (s) displayed
below.
Each Loan Repayment Program has a different eligibility criteria and service requirements based on your
discipline and specialty. Review the Application and Program Guidance for each program before
selecting your application type.
You will not be able to change your application type after May 28, 2019, the application deadline.
Certain applicants may be eligible for multiple Loan Repayment programs. The NHSC will review the
information you submitted to determine your eligibility for multiple Loan Repayment Programs and will
contact you if you are eligible for an award in more than one program. If the NHSC determines that an
applicant is eligible for multiple awards, the applicant will have an opportunity to accept an award in
only one program. However, the NHSC cannot guarantee that you will be offered an award under the
preferred NHSC program.

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where applicants can view the APGs
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necessary.
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* required field
APPLYING FOR
Application Type *

2 Year Full Time
2 Year Half Time
3 Year Full-Time (Rural Community)
3 Year Half-Time (Rural Community)
3 Year Full-Time (Substance Use Disorder Workforce)
3 Year Half-Time (Substance Use Disorder Workforce)

1. Have you completed a Primary Care Training Enhancement (PCTE): Training Primary Care Champions
Fellowship? (for physicians and physician assistant only)
Yes

2. Will you complete a Primary Care Training Enhancement (PCTE): Training Primary Care Champions
Fellowship by July 18, 2020? (For physicians and physician assistant only)
Yes

3. Do you provide substance use disorder services (e.g. Buprenorphine treatment or substance use
disorder counseling) at your site? *
4. Are you licensed or certified in your state to provide substance use disorder services? If yes, please
upload your credentials in the Supporting Documents section. *
7

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additional information

Yes

5. Do you possess a DATA 2000 waiver? If yes, please upload your waiver in the Supporting Documents
section. *
6. Will you have substance use disorder training or certification completed by July 18, 2020? *
Yes

7. I am applying to work at a NHSC-approved site because of the: (Check all that apply) *
Loan repayment incentive
Substance Use Disorder treatment incentive
Opportunity to work with an underserved population
Interest in working in an underserved area
Opportunity to serve in a rural area
Location relative to my home community
None of the above

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information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

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4-General Information Page.docx DRAFT
General Information
* required field
Note: If you have started a fiscal year 2019 application to other NHSC or NURSE Corps programs, the
personal information you enter in this section, such as your name, address, date of birth, birth location,
and Social Security number will overwrite the personal information you provided with the other
applications when you select "Continue" at the end of this section.

FULL NAME
First Name *
Last Name *
thayer
8

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Middle Initial
Title
Suffix
Former First Name
Former Last Name

PREFERRED MAILING ADDRESS
Address Line 1 *
Address Line 2
Country *
State/Province/Region/Territory *
City *
Zip/Postal Code *

PHONE
My preferred phone is an international number
Preferred Phone *
My alternate phone is an international number
Alternate Phone

SOCIAL SECURITY NUMBER
SSN Tooltip

PLACE OF BIRTH
Country *
State/Province/Region/Territory *
City *
Date of Birth *

DEMOGRAPHICS
Award selection will not be determined by this section
Gender

Male

Female
Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

American Indian or Alaskan Native

You may multi-select

Asian

different race values.

Black or African-American

Native Hawaiian or Other Pacific Islander
White
Other
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DISADVANTAGED BACKGROUND TOOLTIP
Have you ever been certified as having come from a disadvantaged background making you eligible to
participate in federal programs such as the Scholarships for Disadvantaged Students, Loans to
Disadvantaged Students, or the Nursing Workforce Diversity Grant Program; or have you ever been the
recipient of a scholarship for students of Exceptional Financial Need? *
Yes

U.S. PUBLIC HEALTH SERVICE
Are you a commissioned officer in the U.S. Public Health Service? *
Yes

NATIONAL PROVIDER IDENTIFIER
Do you have an individual NPI Number? * * Tooltip
Yes

NPI Number:
Forgot Your NPI Number?
Find your NPI Number by visiting the NPI Registry
Enable pop-ups to open the link or access the NPI Registry online: https://npiregistry.cms.hhs.gov/
10

HOW DID YOU HEAR ABOUT NHSC LOAN REPAYMENT PROGRAM
How did you hear about the NHSC LRP? *

SERVICE BEYOND YOUR NHSC OBLIGATION
Do you (and if applicable, your family) plan to remain in the community in which you will fulfill your
NHSC service obligation, if you receive an award, beyond your service obligation? *
Yes

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information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

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5-Discipline and Training Page.docx DRAFT
Discipline, Training, and Certification
* required field
In this section you will identify the discipline/specialty for which you are licensed to provide clinical
services and your degree information. The options provided are specific to the current list of NHSC Loan
Repayment Program approved disciplines and specialties. Please review the education, training and
certifications requirements for your discipline/specialty as defined in the 2019 NHSC Loan Repayment
Program (LRP) Application and Program Guidance, the 2020 NHSC Substance Use Disorder (SUD)
Workforce LRP Application and Program Guidance or the 2020 NHSC Rural Community LRP Application
and Program Guidance. You will certify the accuracy and truthfulness of your selections before you
submit your complete application. If the NHSC cannot verify the information, you entered or If you have
not obtained the appropriate training, certification and license for your discipline and specialty or will
not begin meeting the NHSC Clinical Practice Requirements for the service type you selected prior to July
18, 2019, you do not qualify for an NHSC Loan Repayment Program contract.

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updated to 2020. Please update the month and day if
necessary.
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options displayed here should be dynamic to the program
the applicant is applying for.

DISCIPLINE AND SPECIALTY
Discipline *
Are you currently eligible to practice your profession independently without supervision? *
Yes

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Do you meet the degree, training and certification requirements for this discipline and specialty, as
defined in the fiscal year 2019 NHSC LRP, NHSC Substance Use Disorder Workforce LRP or the NHSC
Rural Community LRP Application and Program Guidance (s)? *
Yes

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By selecting this discipline, you are certifying that you currently possess a master's degree or higher
degree with a major study in counseling from a school accredited by a U.S. Department of Education
nationally recognized regional or State institutional accrediting agency; and, successfully completed at
least 2 years of post-graduate supervised clinical experience as an LPC.

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content for each discipline type.
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DEGREE
When did you receive the health profession degree relevant to the above information selected? *
Type of Degree or Certificate *

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information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

6-Employment Page.docx 2 Year DRAFT
Commented [LM(39]: NHSC 2-Year LRP Draft

* required field
National Health Service Corps (NHSC) Employment Requirement
Applicants for the NHSC Loan Repayment Program must be employed at a NHSC-approved site that is
located in federally designated Health Professional Shortage Area (HPSA). HPSAs are designated as
having a shortage of primary medical care, mental health and dental healthcare professionals. NHSC use
HPSA scores and statuses, along with the eligibility requirements, as detailed in the 2019 Application
and Program Guidance (APG).
For the most up-to-date HPSA and NHSC-approved service sites across the Nation, please go to the
Health Workforce Connector.

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Select your NHSC-approved service site(s).
Note: You may see multiple sites with the same name but, different addresses. Select the site(s) where
you actually provide direct patient care and will meet the NHSC Clinical Practice Requirements for your
discipline/specialty.
State or Territory
City
Check this box if your site is not listed in the search results.
If you are unable to select a site, please contact [email protected]
12

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potential updated form

Have you listed each site where you work or will begin working? *
Yes, all of my sites have been added.
No, some of my sites are not yet added. I will come back to this section and add them before submitting.
Telehealth Services
Do you or will you personally provide some form of telehealth in your clinical practice? Tooltip
Yes
No
I don't know

When providing telehealth:
I am the clinician at the originating site whose patient is receiving the consult/care
I am the clinician at the distant site providing the consult/care
I don't know
Other

What percentage of your clinical practice is/will be spent providing telehealth services?
<10%
10-24%
25-49%
50%>
I don't know

Commented [MF44]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

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6-Employment Page.docx RC DRAFT
Commented [LM(46]: NHSC Rural Community LRP Draft

Employment
* required field
National Health Service Corps (NHSC) Employment Requirement
Applicants for the NHSC Rural Community Loan Repayment Program must be employed at an active
rural NHSC-approved SUD treatment facilities located in federally designated Health Professional
Shortage Area (HPSA). For purposes of the Rural Community LRP, HPSAs are designated as having a
shortage of primary medical care and/or mental health professionals. The NHSC will review your
employment information and eligibility requirements, as detailed in the 2019 NHSC Rural Community
LRP (APG).
For the most up-to-date HPSA and NHSC-approved service sites across the Nation, please go to the
Health Workforce Connector.

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updated to 2020.
Commented [MF48]: Hyperlink APG
Commented [LM(49]: Hyperlink

Select your NHSC-approved service site(s).
Note: You may see multiple sites with the same name but different addresses. Select the site(s) where
you actually provide direct patient care and will meet the NHSC Clinical Practice Requirements for your
discipline/specialty.
If you are unable to add your preferred site(s) to your application, it may not have received the additional
NHSC approval for substance use disorder treatment. If you apply to multiple sites, all of your selected
sites must meet the Substance Use Disorder requirements

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State or Territory
City
Check this box if your site is not listed in the search results.

If you are unable to select a site, please contact [email protected]
Have you listed each site where you work or will begin working? *
Yes, all of my sites have been added.
No, some of my sites are not yet added. I will come back to this section and add them before submitting.

Telehealth Services
Do you or will you personally provide some form of telehealth in your clinical practice? Tooltip
Yes
No
14

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not found form

I don't know

When providing telehealth:
I am the clinician at the originating site whose patient is receiving the consult/care
I am the clinician at the distant site providing the consult/care
I don't know
Other

What percentage of your clinical practice is/will be spent providing telehealth services?
<10%
10-24%
25-49%
50%>
I don't know

Commented [MF52]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Commented [LM(53R52]: Pending

6-Employment Page.docx SUD DRAFT
Employment
* required field
National Health Service Corps (NHSC) Employment Requirement
Applicants for a NHSC Substance Use Disorder (SUD) Workforce Loan Repayment Program (LRP) award
must be employed and providing evidence-based clinical services at active NHSC-approved SUD,
treatment facilities located in federally designated Health Professional Shortage Area (HPSA). For
purposes of the SUD Workforce LRP, HPSAs are designated as having a shortage of primary medical care
and/or mental health professionals. The NHSC will review your employment information and eligibility
requirements, as detailed in the 2019 NHSC Substance Use Disorder (SUD) Workforce LRP (APG), to
determine who is selected for an LRP contract each year.
Applicants for the Substance Use Disorder Workforce LRP contract must be employed at an active NHSCapproved SUD treatment Facility.
For the most up-to-date HPSA and NHSC-approved service sites across the Nation, please go to the
Health Workforce Connector.
15

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Commented [MF55]: Hyperlink APG

Commented [LM(56]: Hyperlink

Select your NHSC-approved service site(s).
Note: You may see multiple sites with the same name but, different addresses. Select the site(s) where
you actually provide direct patient care and will meet the NHSC Clinical Practice Requirements for your
discipline/specialty.
Note: You may see multiple sites with the same name but different addresses. Select the site(s) where
you actually provide direct patient care and will meet the NHSC Clinical Practice Requirements for your
discipline/specialty.

State or Territory
City
Check this box if your site is not listed in the search results.

Telehealth Services
Do you or will you personally provide some form of telehealth in your clinical practice? Tooltip
Yes
No
I don't know

When providing telehealth:
I am the clinician at the originating site whose patient is receiving the consult/care
I am the clinician at the distant site providing the consult/care
I don't know
Other

Commented [LM(57]: Potential updates to employment
not found form

What percentage of your clinical practice is/will be spent providing telehealth services?
<10%
10-24%
25-49%
50%>
I don't know

Commented [MF58]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Commented [LM(59R58]: Pending

7-Employment Verification Page.docx DRAFT
Employment Verification
To begin the Employment Verification (EV) process, select "Initiate" next to the site(s) listed below. The
NHSC POC(s) will receive an email instructing them to verify your employment by logging into the
Program Portal for Site POCs. For detailed information about the site including the POC(s) on file, click
on the site name below. You are responsible for ensuring that your site POC has submitted the
employment verification form on your behalf by the May 28, 2019, application deadline! Once you have
submitted your application you will have the ability to review the responses made by your employer.
Instructions for viewing your application and the EV responses are provided once you submit your
application. For additional information regarding the employment verification process see the NHSC
Employment Verification FAQs.

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updated to 2020. Please update the month and day if
necessary.

CURRENT REQUESTS
Site Name

Verification Type

SouthEast Alaska Regional Health Consortium

Application

Date Created

Status Action

12/31/2018

Complete View

Mt. Edgecumbe Hospital (CAH)

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information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

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8-Loans Pages.docx DRAFT
Loan Information
In this section, you will be required to add the loans that you want approved for repayment under the
NHSC Loan Repayment Program.
To expedite this process, you may import your federal student loan(s) from the U.S. Department of
Education's National Student Loan Data System (NSLDS) directly into the online application. For loans
imported from the NSLDS, no supporting documents are required.
To Access Your Federal Student Loan(s) use the "Access your Loans" button below. You will be directed
to the Department of Education's Federal Student Aid login page and required to log in using your
Federal Student Aid ID (FSA ID). If you have any questions about your FSA ID, please visit:
https://www.nslds.ed.gov/npas/pub/faq.htm
After successfully logging in to FSA, you will be automatically directed back to your application with your
loans displayed below. Once your loans have been imported, please ensure all loans you wish to submit
are listed. You may also select the 'Return to Source' button from the FSA ID Login screen at any time.
For additional loans that are not covered in the NSLDS and may be private education loans, you can still
manually enter the loans along with supporting documents. Any loans that do not appear in your NSLDS
account must be added to your application manually. If you attempt to add a loan that you believe is
NOT a federal student loan(s), but receive an error message, please check the loan data and try again. It
is possible that the loan is a duplicate to one that you have added electronically.
Important Note: If you experience any technical difficulties, please contact the Bureau of Health
Workforce's Customer Care Center at 1-800-221-9393 (TTY: 1-877-897-9910) Monday through Friday
(except federal holidays) from 8:00 AM to 8:00 PM ET or email us. If you are unable to resolve your
technical difficulties or concerns in time to submit your complete application prior to May 28, 2019, the
application deadline, please enter your loans manually. The period for submitting applications will not be
extended due to difficulties with submitting your loans.
To manually add Loans click the "Need Help?" link to manually add loans you wish to submit for loan
repayment.
When entering your loan information manually, you must enter loan information and supporting
documentation for each servicing lender that you wish to be considered for repayment. The following
documents will be required:


Account Statement (Both Private and Federal) - Most recent statement from your
lender/servicer that has your name, current loan balance and interest rate. This may be the
official paper version, or a printed web version, that is scanned, uploaded, and not older than 30
days from the date you will submit your application.



NSLDS Aid Summary Report (Federal Loans) - Most recent summary report taken from your
National Student Loan Data Systems (NSLDS) account. This may be the official paper version, or
a printed web version, that is scanned and uploaded. Note: This is the summary report only,

Commented [MF63]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.

which lists your federal student loans in one document and is available at
http://www.nslds.ed.gov.


Disbursement Report or Promissory Note (Non-Federal Loans) - A copy of the document
provided by your lender/servicer that outlines the details of your loan agreement, including your
name, the date the loan was obtained, the purpose of the loan, account numbers, and the loans
included in a consolidation (if applicable).

If you have a consolidated loan, you must enter in all of the information in the table. All of the
information must coincide with the information in the loan documents. If they do not coincide, the loan
will be deemed ineligible.

LOG INTO YOUR NATIONAL STUDENT LOAN DATA SYSTEM ACCOUNT
NEED HELP?
Don't have a Federal Student Aid ID or want to enter loans manually?

MANUALLY ADDED LOANS
]
Name Account #

Balance Interest Rate

FedLoan Servicing

5012836983

Submitted All Required Docs ? Action

$139,523.59

6.630%

Yes

Edit

Commented [MF64]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Commented [LM(65R64]: Pending

Loan Details
* required field
Back to Loan Information
You have elected to add your qualifying education loans to your application manually. This method is
required for adding ALL loans that are NOT federal student loan(s). If you have elected to add your
federal student loan(s) using this method you must not attempt to add them using the electronic import
method, or you will receive an error message and put you at risk of missing the application deadline.
You are strongly encouraged to print and read the NHSC Loan Module Detailed Instructions before
adding your loans

Include all qualifying education loans, even if they exceed the maximum award amount. Please exclude
letters, special characters (i.e. $, %), and commas when entering outstanding loan balances and interest
rates. If you have multiple loans with the same servicer/lender, you must enter each loan separately.
To add your loans successfully and to ensure that your loans have the best chance to qualify for
repayment when reviewed, you must retrieve, scan and upload the current account statements from
your loan servicers and the Aid Summary Report from your NSLDS online account (federal student
loan(s)) or a disbursement report for any private loans, for each loan.
For each field completed below, the supporting documents must verify the information you have
entered.

Name of current servicing lender *
Loan account number *
Original date of the loan * Tooltip
Original amount of the loan *
Current balance (Principal & accrued Interest) *
Type of loan * Tooltip
Is this loan in default? * Is this loan in default? *
Yes

Is this loan under federal court judgment? *
Yes

Purpose of loan *
Is this a consolidated loan? *
Yes

No
Commented [MF66]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Supporting Documents
Back to Loan Information
The following loan documents are required to assess whether your loans qualify for repayment under
the NHSC Loan Repayment Program. Each document should only be uploaded to the loan that it reflects.
Each document should show clear verification that it is official and comes from the Servicer/Lender. In
most cases, the required information can be obtained from official web-accounts or found on paper
documents that you have received from the servicer or lender. They can be printed, scanned, and
uploaded to your application in this section.
20

The account statements should only be obtained directly from the lender/servicer. Documents can be
printed, scanned, and uploaded to your application in this section.
A description of the required information for each document type can be found below. If a required
document does not contain the required information or is not legible enough to review the loan profile,
it will be deemed "incomplete" and the loan itself will not qualify for repayment.

ACCOUNT STATEMENTS
LOAN ORIGINATION AND DISBURSEMENT REPORTS
CONSOLIDATED EDUCATIONAL LOANS
Please note: The following file types are not suitable for being uploaded: jpg, doc, xls & tif. Password
protected files are not acceptable and will disqualify the loan. Loan documents must be official and
obtained directly from the lender/servicer. Copies of website versions are acceptable.

UPLOADED DOCUMENTS
Document Title

Document File

Status

Action

Account Statement

Received

Remove

NSLDS/Aid Summary Report

Received

Remove

Consolidated Loan Supporting Document

Received

Remove

UPLOAD DOCUMENT
Account Statement
NSLDS/Aid Summary Report
Consolidated Loan Supporting Document

Commented [MF67]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

8-Supporting Documents Page.docx DRAFT
Supporting Documents
* required field
You are encouraged to save your documents as .PDF files before uploading to your application. You
should not attempt to upload documents larger than 5MB, or files formatted as .TIFF, .JPEG, .PNG and
.TXT. In addition, the NHSC must be able to review the details of your application documents clearly.
Submitting pictures, password protected, and incomplete or illegible documents will disqualify your
21

application from consideration. All information provided in the supporting documents and online
application must match exactly. Any disparities will cause your application to be deemed ineligible.

PROPER USE OF AWARD
For use by Former NHSC Loan Repayment Program Participants ONLY!
If you are a former NHSC Loan Repayment Program participant, you are required to upload official
documentation that will verify your use of the entire amount award you received with your most recent
contract, to pay down the education loans that were approved for repayment with your most recent
award.
Example: If you were disbursed $50,000 in 2002 and completed your service in 2004, you are required to
upload documentation verifying that you paid $50,000 to the loans that were approved for repayment
within that contract obligation period.
If you are not able to provide documentation at the time you submit your application that clearly
verifies that you paid the entire amount within that contract period to the loans that were approved,
your application will be disqualified during review and you will not be eligible for participation in NHSC
programs indefinitely. Please provide the following required documents:


Proof of Payment History for Prior NHSC LRP Service - Mandatory for Previous NHSC LRP
Participants.



Proof of U.S. Citizenship or U.S. National - Current passport, birth certificate, or nationalized
citizenship certificate.



Substance Use Disorder License or Certification (if applicable) - certificate of completion or
diploma from a Substance Use Disorder or Addiction medicine training program(s).

ADDITIONAL DOCUMENTS


Proof of Payment History for Prior NHSC LRP Service



Verification of Disadvantaged Background

Commented [LM(68]: Hyperlink to updated document

UPLOAD DOCUMENTS
Document Title

Document File

Status

Delete

DATA 2000 Waiver

Not Received

Proof of Payment History for Prior NHSC LRP Service

Not Received

Proof of U.S. Citizenship or U.S. National

Received

delete

Substance Use Disorder Licensure or Certification

Received

delete

Additional Supporting Document

Not Received

LOAN DOCUMENTS
Servicing Lender & Account #

Document Title

Document File

Status

FedLoan Servicing 5012836983 NSLDS/Aid Summary Report

Received

FedLoan Servicing 5012836983 Account Statement

Received

FedLoan Servicing 5012836983 Consolidated Loan Supporting Document

Commented [MF69]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Commented [LM(70R69]: Pending

10-Self Certification Page.docx DRAFT
Self-Certification
* required field
1. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, DISQUALIFICATION AND RELATED MATTERS
FORM


Pursuant to 2 CFR 180.335 (2006) as implemented by 2 CFR 376.10 (2007), an applicant applying
to enter into a covered transaction (which includes an application to participate in the NHSC
LRP) is required to notify the Federal agency office if the applicant knows that he or she:



Is presently debarred, suspended, excluded, or disqualified from participation in covered
transactions by any Federal agency or department;



Within the 3-year period preceding the application, has been convicted of, or had a civil
judgment rendered against him or her for any of the following offenses:


Commission of fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (Federal, State, or local) transaction or a contract under a
public transaction;



Violation of Federal or State antitrust statutes;



Commission of embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, tax evasion, receiving stolen property, making false
claims, or obstruction of justice; or



Commission of any other offense indicating a lack of business integrity or business
honesty that seriously and directly affects his/her present responsibility



Is presently indicated or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with the commission of any of the offenses set forth above; or



Within a 3-year period preceding the application, has had any public transaction (Federal, State,
or local) terminated for cause or default.

I certify that none of the above statements apply to me.

2. AUTHORIZATION FOR DISCLOSURE OF FINANCIAL INFORMATION
Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 USC 3404), having read the statement
of my RFPA rights, I hereby authorize the government or financial institution named in item 1 on each
Loan Details page to release financial records relating to educational loans(s) identified on the Loan
Details page to the HHS for the purpose of assessing and verifying the amount and eligibility of the
educational loan for payment under the HHS. This authorization is valid for 3 months from the date of
my signature, and may be revoked in writing at any time before my records are disclosed. *

3. CERTIFY BY CHECKING THE BOX NEXT TO THE STATEMENTS BELOW:
I certify that I have read and understood the appropriate Application and Program Guidance (s) for the
program to which I am applying for a FY 2020 contract NHSC LRP, NHSC Substance Use Disorder (SUD)
Workforce LRP or NHSC Rural Community (RC) LRP.
I certify that I have a master's degree or higher degree with a major study in counseling from a school
accredited by a 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.

Commented [MF71]: This year will automatically be
updated to 2020.
Commented [MF72]: This year will automatically be
updated to 2020.
Commented [LM(73]: Hyperlink each program

I certify to one of the statements below:


LPCs With a License in State of Practice: I certify that I have a current full, permanent,
unencumbered, unrestricted health professional license, certificate, or registration to practice
independently and unsupervised as an LPC in the State in which I intend to practice as an NHSC
Loan Repayment Program participant.



LPCs Without a License in State of Practice: I certify that licensure as an LPC is not available in
the State in which I intend to practice as an NHSC Loan Repayment Program participant, and
that I have a current, full, permanent, unencumbered, unrestricted health professional license,
certificate, or registration to practice independently and unsupervised as an LPC in a State.

I certify that all of the information that I have provided in this application and required supplemental
documents is true.

Commented [LM(74]: For DBO/Sapient is this discipline
specific?

Commented [MF75]: Please make updates if OMB
information has changed.

OMB No. 0915-0127 Expiration Date: 02/29/2020

Commented [LM(76R75]: Pending

APPLICATION PAGES
COI Pages
1-Accept or Decline Award Page 2 Year DRAFT
Loan Repayment Program Application
Congratulations! You are being considered for the FY 2020 National Health Service Corps (NHSC) Loan
Repayment Program (LRP). Your overall Application Status is: Finalist for Award. Please note that while
you have been considered for the LRP, this is NOT a guarantee of an award, as all NHSC awards are
subject to the availability of funds.

Commented [MF77]: This year will automatically be
updated to 2020.
Commented [AI(78]: Suggest rephrasing the term
“selected” in the sentence. See my update.

View your submitted application.
To confirm your intent to accept an award, please complete the following steps by the end of the day on
April 19, 2019. You should base your decision to accept or decline an award on your understanding of,
and ability to adhere to, the NHSC Loan Repayment Program guidelines and service requirements.
Before indicating your choice below, please review and understand the program guidelines and service
requirements as outlined in the FY 2020 NHSC LRP Application and Program Guidance.
If you have questions or want to dispute the information we have verified before confirming your
continued interest, please contact the NHSC LRP at 1-800-221-9393.
Please complete the following steps:
Step 1 Review and verify the contact information we have for you in our records by clicking on the
account settings page. Applicants with inaccurate contact information risk not receiving crucial award
and program information.
Step 2
Review the results of our verification of the loans that you submitted with your application. Participants
with eligible debt that exceeds the maximum award will receive the maximum award. See the table
below for NHSC award amounts.
Program

Years of Contract

Full-time Service

Half-time Service

NHSC LRP

$50,000.00

$25,000.00

Note: Loans that are not eligible for the LRP will read $0.00 in the Eligible Amount column.

NHSC Verified Loans
Account / Loan Number Loan Type

Servicer Current Balance Eligible Amount

7656208306

Manual

MOHELA

$6,950.31

7656208306

Manual

MOHELA

$22,980.00

Commented [MF79]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.
Commented [LM(80]: Hyperlink APG

7656208306

Manual

MOHELA

$608.95

7656208306

Manual

MOHELA

$6,683.10

7656208306

Manual

MOHELA

$11,125.02

7656208306

Manual

MOHELA

$1,000.71

9249

Manual

Navient

$1,994.57

7656208306

Manual

MOHELA

$12,506.67

Total Approved $63,849.33

Projected Award

$64,757.33

For Repayment:

Disbursement:

Step 3 Review and verify the name and address of the NHSC-approved service site(s) that were verified
and approved for your service.

Site Information
Site Name

Site Address

Western Wayne Family Health Center-Inkster 2700 Hamlin Dr.

NHSC Status
ACTIVE

Inkster, Michigan 48141-2348

Are you currently working at the NHSC verified and approved service site(s) listed above and are
meeting the NHSC's definition of full-time clinical practice and will to the best of your knowledge
continue to meet that definition?
Yes

Commented [LM(81]: This should be automatically
updated based on the contract type, full-time vs. part-time

Step 4 Once you confirm or decline your interest in receiving an award, the NHSC Loan Repayment
Program will proceed without further notice based on the option you have selected. ** If you do not
respond by April 19, 2019, indicating that you still wish to be considered for an award, your application
may be removed from consideration.
I ACCEPT the FY 2020 NHSC Loan Repayment Program award.
I DECLINE the FY 2020 NHSC Loan Repayment Program award.
I understand that I will no longer be considered for a FY 2020 NHSC LRP (2 –year) award.

Commented [MF82]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.
Commented [MF83]: This year will automatically be
updated to 2020.
Commented [MF84]: This year will automatically be
updated to 2020.
Commented [LM(85]: Should be dynamic based on
program
Commented [LM(86]: Should be dynamic based on
program

Step 5 Please enter your banking information for the account in which your NHSC Loan Repayment
Program funds should be deposited. Note: Release of your award funds is contingent on a fully executed
NHSC Loan Repayment Program contract (i.e., signed by both parties) and your satisfactory performance
of at least 90 days of NHSC service.

Bank Name *
Account Type *
Routing Number * Tooltip
Re-enter Routing Number *
Account Number * Tooltip
Re-enter Account Number *

Decline Offer of the NHSC LRP Award
* required field
Back
You have selected to decline the offer to receive a NHSC Loan Repayment Program award and you no
longer wish to be considered during the current award period. This action cannot be reversed.
Please indicate your reason for declining the
NHSC Loan Repayment Program award. *

If you choose to apply in the future, you must submit an application during one of our "open"
application cycles for new participants and compete with other providers based on program
requirements at that time.

1-Accept or Decline Award Page RC LRP DRAFT

Rural Community Loan Repayment Program Application
Congratulations! You are being considered for the FY 2020 National Health Service Corps (NHSC) Rural
Community Loan Repayment Program (LRP). Your overall Application Status is: Finalist for Award.
Please note that while you have been considered for the LRP, this is NOT a guarantee of an award, as all
NHSC awards are subject to the availability of funds. View your submitted application.
View your submitted application.
27

Commented [MF87]: This year will automatically be
updated to 2020.
Commented [AI(88]: Suggest rephrasing the term
“selected” in the sentence. See my update.

To confirm your intent to accept an award, please complete the following steps by the end of the day on
April 19, 2019. You should base your decision to accept or decline an award on your understanding of,
and ability to adhere to the NHSC Rural Community LRP Program guidelines and service requirements.
Before indicating your choice below, please review and understand the program guidelines and
service requirements as outlined in the FY 2020 Rural Community LRP Application and Program
Guidance.
If you have questions or want to dispute the information we have verified before confirming your
continued interest, please contact the NHSC LLRP at 1-800-221-9393.
Please complete the following steps:
Step 1

Review and verify the contact information by clicking on the account settings page.
Applicants with inaccurate contact information risk not receiving crucial award and
program information.

Step 2

Review the results of our verification of the loans that you submitted with your
application. Participants with eligible debt that exceeds the maximum award will receive
the maximum award. See the table below for NHSC award amounts.

Program
NHSC Rural Community LRP

Years of Contract
3

Full-time Service
$100,000.00

Half-time Service
$50,000.00

Note: Loans that are not eligible for the LRP will read $0.00 in the Eligible Amount
column.
NHSC Verified Loans
Account / Loan Number Loan Type

Servicer Current Balance Eligible Amount

7656208306

Manual

MOHELA

$6,950.31

7656208306

Manual

MOHELA

$22,980.00

7656208306

Manual

MOHELA

$608.95

7656208306

Manual

MOHELA

$6,683.10

7656208306

Manual

MOHELA

$11,125.02

7656208306

Manual

MOHELA

$1,000.71

9249

Manual

Navient

$1,994.57

7656208306

Manual

MOHELA

$12,506.67

Projected Award
Disbursement:

$64,757.33

Total Approved $63,849.33
For Repayment:
Step 3

Review and verify the name and address of the NHSC-approved service site(s) that were
verified and approved for your service.
28

Commented [MF89]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.

Commented [LM(90]: Hyperlink APG

Site Information
Site Name

Site Address

NHSC Status

Western Wayne Family Health Center-Inkster 2700 Hamlin Dr.
ACTIVE
Inkster, Michigan 48141-2348
Are you currently working at the NHSC verified and approved service site(s) listed above
and are meeting the NHSC's definition of full-time clinical practice and will to the best of
your knowledge continue to meet that definition?
Yes

Step 4

Commented [LM(91]: This should be automatically
updated based on the contract type, full-time vs. part-time

Once you confirm or decline your interest in receiving an award, the NHSC Rural
Community LRP will proceed without further notice based on the option you have
selected. ** If you do not respond by April 19, 2019, indicating that you still wish to be
considered for an award, your application may be removed from consideration.

Commented [MF92]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.

I ACCEPT the FY 2020 NHSC Rural Community LRP award.
I DECLINE the FY 2020 NHSC Rural Community LRP award. I understand that I
will no longer be considered for a FY 2020 NHSC Rural Community LRP award.
Step 5

Please enter your banking information for the account in which your NHSC Rural
Community LRP funds should be deposited. Note: Release of your award funds is
contingent on a fully executed NHSC Rural Community LRP contract (i.e., signed by both
parties) and your satisfactory performance of at least 90 days of NHSC service.

Bank Name *
Account Type *
Routing Number * Tooltip
Re-enter Routing Number *
Account Number * Tooltip
Re-enter Account Number *

Decline Offer of the NHSC Rural Community LRP Award
* required field
Back

Commented [LM(93]: Should be dynamic based on
program

You have selected to decline the offer to receive a NHSC Loan Repayment Program award and you no
longer wish to be considered during the current award period. This action cannot be reversed.
Please indicate your reason for declining the
NHSC Loan Repayment Program award. *

See screenshots of first COI page below:

1-Accept or Decline Award Page SUD DRAFT
Substance Use Disorder Workforce Loan Repayment Program Application
Congratulations! You are being considered for the FY 2020 National Health Service Corps (NHSC)
Substance Use Disorder (SUD) Loan Repayment Program (LRP). Your overall Application Status is:
Finalist for Award. Please note that while you have been considered for the LRP, this is NOT a guarantee
of an award, as all NHSC awards are subject to the availability of funds. View your submitted application.

Commented [MF94]: This year will automatically be
updated to 2020.
Commented [AI(95]: Suggest rephrasing the term
“selected” in the sentence. See my update.

View your submitted application.
To confirm your intent to accept an award, please complete the following steps by the end of the day on
April 19, 2019. You should base your decision to accept or decline an award on your understanding of,
and ability to adhere to, the NHSC SUD Workforce LRP Program guidelines and service requirements,
Before indicating your choice below, please review and understand the program guidelines and service
requirements as outlined in the FY 2020 SUD Workforce LRP Application and Program Guidance.
If you have questions or want to dispute the information we have verified before confirming your
continued interest, please contact the NHSC LLRP at 1-800-221-9393.
Please complete the following steps:
Step 1 Review and verify the contact information we have for you in our records by clicking on the
account settings page. Applicants with inaccurate contact information risk not receiving crucial award
and program information.

Step 2 Review the results of our verification of the loans that you submitted with your application.
Participants with eligible debt that exceeds the maximum award will receive the maximum award. See
the table below for NHSC award amounts.
Program

Years of Contract

Full-time Service

Half-time Service

Commented [MF96]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.
Commented [LM(97]: Hyperlink APG

NHSC SUD Workforce LRP

$75,000.00

$37,500.00

Note: Loans that are not eligible for the LRP will read $0.00 in the Eligible Amount column.
NHSC Verified Loans
Account / Loan Number Loan Type

Servicer Current Balance Eligible Amount

7656208306

Manual

MOHELA

$6,950.31

7656208306

Manual

MOHELA

$22,980.00

7656208306

Manual

MOHELA

$608.95

7656208306

Manual

MOHELA

$6,683.10

7656208306

Manual

MOHELA

$11,125.02

7656208306

Manual

MOHELA

$1,000.71

9249

Manual

Navient

$1,994.57

7656208306

Manual

MOHELA

$12,506.67

Total Approved $63,849.33

Projected Award

$64,757.33

For Repayment:

Disbursement:

Step 3 Review and verify the name and address of the NHSC-approved service site(s) that were verified
and approved for your service.

Site Information
Site Name

Site Address

Western Wayne Family Health Center-Inkster 2700 Hamlin Dr.

NHSC Status
ACTIVE

Inkster, Michigan 48141-2348

Are you currently working at the NHSC verified and approved service site (s) and meeting the NHSC's
definition of full-time clinical practice and will to the best of your knowledge continue to meet that
definition at the NHSC-approved service site(s) listed above? Please verify that the address(es) match
your current work location(s). *
Yes

Commented [LM(98]: This should be automatically
updated based on the contract type. Full-time vs Part-time

Step 4 Once you confirm or decline your interest in receiving an award, the NHSC SUD Workforce LRP
will proceed without further notice based on the option you have selected. ** If you do not respond by
April 19, 2019, indicating that you still wish to be considered for an award, your application may be
removed from consideration.

Commented [MF99]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.

I ACCEPT the FY 2020 NHSC SUD Workforce Loan Repayment Program award.
I DECLINE the 2020 NHSC SUD Workforce LRP award. I understand that I will no longer be considered
for a FY 2020 NHSC SUD workforce LRP award.
Step 5 Please enter your banking information for the account in which your NHSC SUD Workforce LRP
funds should be deposited. Note: Release of your award funds is contingent on a fully executed NHSC
SUD Workforce LRP contract (i.e., signed by both parties) and your satisfactory performance of at least
90 days of NHSC service.

Bank Name *
Account Type *
Routing Number * Tooltip
Re-enter Routing Number *
Account Number * Tooltip
Re-enter Account Number *

Decline Offer of the NHSC SUD Workforce LRP Award
* required field
Back
You have selected to decline the offer to receive a NHSC Loan Repayment Program award and you no
longer wish to be considered during the current award period. This action cannot be reversed.
Please indicate your reason for declining the
NHSC Loan Repayment Program award. *

Commented [MF100]: This year will automatically be
updated to 2020.
Commented [LM(101]: Should be dynamic based on
program

2-Sign Electronic Contract Page.docx DRAFT
Commented [LM(102]:

Sign your Electronic Contract
* required field
Back
This NHSC Loan Repayment Program, NHSC Rural Community Loan Repayment Program or NHSC
Substance Use Disorder Workforce Loan Repayment Program contract is not binding until countersigned
by the Secretary of the Department of Health and Human Services or his/her designee.
View a printable version of the NHSC Loan Repayment Program, NHSC Rural Community Loan
Repayment Program or NHSC Substance Use Disorder Workforce Loan Repayment Program contract

Commented [LM(103]: Should be dynamic per program

Commented [LM(104]: Should Be dynamic per program

CONTRACT

CERTIFICATION
I certify that I have read the above contract in its entirety and my electronic signature on this contract is
intended to be the legally binding equivalent of my handwritten signature.
Yes

ENTER SIGNATURE INFORMATION
SSN * Tooltip
Confirm SSN *
What is the street number of the house you grew up in? * Tooltip
Password *

3-Submitted Landing Page. DRAFT docx
Loan Repayment Program Application
Hello Cheryl,
You have confirmed your intent to accept the 2019 National Health Service Corps (NHSC) Loan
Repayment Program (LRP), NHSC Rural Community Loan Repayment Program or NHSC Substance Use
Disorder Workforce Loan Repayment Program (LRP) award. You are not guaranteed an award at this
time.
The NHSC uses your primary email address to communicate application status changes and requests for
additional information regarding your application. Please ensure that we always have the most accurate
contact information.
33

Commented [MF105]: This year will automatically be
updated to 2020.
Commented [LM(106]: Should be dynamic based on
program

Commented [MF107]: This year will automatically be
updated to 2020. Please update the month and day if
necessary.

All awards will be made by September 30th 2019.
Your overall application status is: Accepted Award - Under Final Review
Your application ID is: 453593

VIEW YOUR SUBMITTED APPLICATION
Commented [LM(108]: Should be dynamic based on
program

Your National Health Service Corps Loan Repayment Program signed contract

EMPLOYMENT VERIFICATIONS
Site Name

Initiation Date Response Date Status

Western Wayne Family Health Center-Inkster

01/20/2019

Complete

GENERAL SUPPORTING DOCUMENTS
Document Title

Document Name

Status

DATA 2000 Waiver

data waiver.pdf

Received

Eligible Health Professional Degree

EMU degree.pdf

Received

Proof of Payment History for Prior NHSC LRP Service

Not Received

Proof of U.S. Citizenship or U.S. National

Received

Passport.pdf

Substance Use Disorder Licensure or Certification 24 hour bup training.pdf

Received

Additional Supporting Document

8 hour Bup training.pdf

Received

Additional Supporting Document

AANP cert.pdf

Received

Additional Supporting Document

ANCC certification.pdf

Received

Additional Supporting Document

NP license.pdf

Received

Additional Supporting Document

MyStudentData.txt

Received

Additional Supporting Document

Not Received

LOAN SUPPORTING DOCUMENTS
Servicing Lender & Account #

Document Title Document File

MOHELA 7656208306 Account Statement

Loan Report-mohela.pdf

MOHELA 7656208306 NSLDS/Aid Summary Report
34

Status
Received

MyStudentData (2).txt Received

MOHELA 7656208306 NSLDS/Aid Summary Report

MyStudentData (2).txt Received

MOHELA 7656208306 Account Statement

Loan Report-mohela.pdf

Received

MOHELA 7656208306 Account Statement

Loan Report-mohela.pdf

Received

MOHELA 7656208306 NSLDS/Aid Summary Report
MOHELA 7656208306 Account Statement

Loan Report-mohela.pdf

MOHELA 7656208306 NSLDS/Aid Summary Report
MOHELA 7656208306 Account Statement

Navient 9249

Account Statement

Navient 9249

NSLDS/Aid Summary Report

Received

MyStudentData (2).txt Received

Navient _ Loan Details.pdf

MOHELA 7656208306 Account Statement

Received

MyStudentData (2).txt Received

Loan Report-mohela.pdf

MOHELA 7656208306 NSLDS/Aid Summary Report

Received

MyStudentData (2).txt Received

Loan Report-mohela.pdf

MOHELA 7656208306 NSLDS/Aid Summary Report
MOHELA 7656208306 Account Statement

MyStudentData (2).txt Received

Received

MyStudentData (2).txt

Received

Loan Report-mohela.pdf

Received

MOHELA 7656208306 NSLDS/Aid Summary Report

MyStudentData (2).txt Received

Participant Portal Pages
My Service Information Page.docx DRAFT
My Service Information
Award Date

04/09/2019

Available For Service

04/09/2019

Commented [MF109]: This year will automatically be
update to 2020.

Recent Verification

NHSC LOAN REPAYMENT PROGRAM WELCOME KIT - 2019
Important documents related to your NHSC Loan Repayment Program award can be found here. You
may refer to or print them at any time. Please take time to review your contract.


Customer Service Portal Activation Instructions



NHSC LRP Application Program Guidance



2019 NHSC LRP New Participant Award Notification



2019 NHSC LRP New Award Payment Authorization Worksheet
35

Commented [LM(110]: Document should be dynamic
based on program type
Commented [MF111]: This year will automatically be
update to 2020.



2019 NHSC LRP Site Award Notification 453593 0530900



Your 2019 Submitted Application



NHSC LRP Contract



Customer Service Portal Activation Instructions



NHSC SUD LRP Application Program Guidance



2019 NHSC SUD Workforce LRP Award Notification



2019 NHSC SUD Workforce LRP Payment Authorization Worksheet



2019 NHSC SUD Workforce LRP Site Award Notification 453593 0530900



Your 2019 Submitted Application



NHSC SUD Workforce LRP Contract

Commented [HO(112]: Need to update the year to 2020.

Commented [HO(113]: Need to update the year to 2020.

Customer Service Portal Activation Instructions


NHSC Rural Community LRP Application Program Guidance



2019 NHSC Rural Community LRP New Participant Award Notification



2019 NHSC Rural Community LRP Payment Authorization Worksheet



2019 NHSC Rural Community Site Award Notification 453593 0530900



Your 2019 Submitted Application



NHSC Rural Community LRP Contract

Commented [HO(114]: Need to update the year to 2020.

Welcome Portal Message.docx DRAFT

Welcome to the National Health Service Corps Loan Repayment Program!
Commented [MF115]: This year will automatically be
updated to 2020.

This message was sent on 04/09/2019.

Congratulations and welcome to the National Health Service Corps (NHSC) Loan Repayment Program!
You have successfully logged into the BHW Customer Service Portal as a NHSC Loan Repayment Program
participant.

Through the portal, you will be able to view your personal information to ensure it is up-to-date and
accurate, make banking information updates, access your NHSC Loan Repayment Program Welcome Kit,
ask questions, and request support on a myriad of program concerns. To access these documents, visit
the "My Service Information" section on the right of the portal homepage and click "View Documents
and Details."
If you see errors in your data or profile information, please submit an inquiry through the BHW
Customer Service Portal or contact the Customer Care Center at 1-800-221-9393 (TTY: 1-877-897-9910)
Monday through Friday (except federal holidays) from 8:00 a.m. to 8:00 p.m. ET.

APPLICATION DOCUMENTS
Application Discipline Section NHSC RC LRP DRAFT
FY 20 NHSC and SUD LRP Application Checklist DRAFT
FY 20 NHSC LRP Disadvantaged Background Verification Form
FY 20 NHSC LRP Full-Time Clinical Practice Requirements DRAFT
FY 20 NHSC LRP Half-Time Clinical Practice Requirements DRAFT
FY 20 NHSC LRP Loan Module Detailed Instruction DRAFT
FY 20 NHSC LRP Participant Salary Reference Guide DRAFT
FY 20 NHSC LRP Proof of Payment DRAFT

File Type	application/pdf
File Title	FY 2020 Combined documents and Content DRAFT
Author	Lewis, Malissa (HRSA)
File Modified	2020-03-20
File Created	2019-11-10