Form 5 PPO Agreement_Final_Clean 2020

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].

PRIVATE PRACTICE OPTION AGREEMENT
The Secretary of Health and Human Services (“Secretary”) is authorized under Section 338D of the Public Health Service Act
(42 U.S.C. § 254n) to release a participant in the National Health Service Corps ("NHSC") Scholarship Program, NHSC Loan Repayment
Program, NHSC Students-to-Service Loan Repayment Program or the NHSC Substance Use Disorder Workforce Loan Repayment
Program (as applicable), from his/her obligation to serve as a Corps member so that the participant (the “Individual”) may instead
serve under the Private Practice Option ("PPO"). Such release is contingent on the Individual submitting an approvable PPO application
and entering into a PPO Agreement with the Secretary.
The Individual entering into this PPO Agreement has submitted a PPO Request Form approved by the Secretary or his/her
designee, and (a) works in an NHSC-approved solo or group practice, with full or partial ownership of the practice; (b) works as a
contractor to an NHSC-approved site (i.e., is not subject to the personnel system of the NHSC‐approved service site at which the
Individual serves; or (c) is employed by the NHSC-approved service site but does not receive a salary and benefits (including
malpractice insurance or tail coverage) at least equal to what the Individual would earn as a federal civilian employee.
Effective Date: This agreement does not take effect, and the Individual will not receive NHSC service credit under the PPO, until the
Secretary, or his or her designee, countersigns this Agreement and the Individual begins full‐time clinical practice, as defined by the
NHSC, at the site(s) identified below.

Individual’s Name (Please Print)

Last Four Digits of SSN

Discipline/Specialty

Site Name:

Site Name:

Address:

Address:

City:

State:

Zip Code:

City:

Site Name:

Site Name:

Address:

Address:

City:

State:

Zip Code:

City:

Phone

State:

Zip Code:

State:

Zip Code:

The Secretary agrees to:
1.

2.

3.
4.

Allow the Individual to serve in the full‐time clinical practice of his or her profession for the remaining period of the
Individual’s NHSC service obligation, at the location(s) specified above, by releasing the Individual from his or her
obligation to serve as a Corps member.
Exercise reasonable care and provide adequate safeguards to assure that the confidentiality of information regarding
patients identified in any records reviewed during the conduct of Department assessments is not compromised by
the misuse of such information.
Provide, upon the Individual’s request and subject to the availability of appropriated funds, technical assistance to the
Individual to assist in fulfilling his/her private practice obligation.
Cancel the Individual’s private practice obligation or default repayment obligation if the Individual dies before fulfilling
either of these obligations.

Secretary of HHS/Designee

Title (if Designee)

Signature

Date

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

The Individual agrees to:
1.

Enter into the full‐time private clinical practice, as defined in Paragraph 2 below, of his or her profession, in a
Health Professional Shortage Area (HPSA) approved by the Secretary to fulfill his/her remaining service
obligation under the PPO. At least eighty (80) percent of the patients served by the Individual must be residents
of the approved HPSA (if a geographic or facility designation) or members of the approved HPSA (if a population
group designation).

2.

Full‐Time Clinical Practice is defined as a minimum of 40 hours per week, for a minimum of 45 weeks per service
year. The remainder of the service year (approximately 7 weeks) may, as authorized by the approved service site(s),
be spent away from the practice for holidays, vacation, continuing professional education, illness, or any other
reason. Failure to meet the minimum 45 weeks per service year will extend the service obligation end date or result
in a breach of the PPO Agreement, as determined by the Secretary. The 40 hours per week may be compressed into
no less than 4 days per week, with no more than 12 hours of work to be performed in any 24‐hour period. Time
spent "on-call" will not count toward the 40-hour week, except to the extent that the applicant provides patient care
during the “on-call” period. Time worked in excess of the minimum 40 hours per week cannot be applied to any
other work week and will not count toward the service obligation.
a. For all health professionals (except as noted below), at least 32 hours of the minimum 40 hours per
week must be spent providing patient care or teaching in the outpatient ambulatory care setting(s) at
the approved service site(s) during normally scheduled office hours. Of the minimum 32 hours per week
for patient care, teaching shall not exceed a total of 8 hours per week. The remaining 8 hours per week
must be spent providing patient care or teaching at the approved service site(s), providing patient care
in alternative settings as directed by the approved service site(s), or performing clinical‐related
administrative activities. Clinical-related administrative, management or other activities shall not exceed
8 hours per week.
b. For obstetricians/gynecologists, family practice physicians who practice obstetrics on a regular basis,
providers of geriatric services, pediatric dentists, and certified nurse‐midwives, at least 21 of the
minimum 40 hours per week must be spent providing patient care in the outpatient ambulatory care
setting(s) at the approved service site(s) during normally scheduled office hours. Of the minimum
21 hours per week of patient care, teaching shall not exceed 8 hours per week. The remaining 19 hours
per week must be spent providing patient care at the approved service site(s), providing patient care in
alternative settings as directed by the approved site(s), or performing clinical‐related administrative
activities (limited to 8 hours per week).
c. For physicians (including psychiatrists), nurse practitioners, physician assistants, and certified nurse‐
midwives serving in a Critical Access Hospital at least 16 of the minimum 40 hours per week must be spent
providing patient care in the CAH‐affiliated outpatient ambulatory care setting(s) at the approved service
site(s) during normally scheduled office hours. Of the minimum 16 hours per week of patient care, teaching
shall not exceed 8 hours per week. The remaining 24 hours per week must be spent providing patient care
at the CAH or the CAH‐affiliated outpatient ambulatory care setting(s), providing patient care in the CAH’s
skilled nursing facility or swing bed unit, or performing clinical‐related administrative activities (limited to
8 hours per week).
d. Telehealth: PPO providers who are self-employed are not eligible for NHSC service credit for telehealth
services. Other PPO providers may receive NHSC service credit for providing telehealth services at NHSCapproved sites, under the following conditions:
(1) Telehealth services must be furnished using an interactive telecommunications system, defined as
multimedia communications equipment that includes, at a minimum, audio and video equipment
permitting two-way, real time interactive communication between the patient at the originating site and
the NHSC clinician at the distant site. Telephones, facsimile machines, and electronic mail systems do not
meet the definition of an interactive telecommunications system;
(2) The Individual will receive NHSC service credit only for telehealth services provided to/from the
distant and originating site(s) initially approved by the NHSC, unless the Individual receives prior written

Page 2 – Private Practice Option Agreement (revised December 2018)

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

approval from the NHSC to provide telehealth services to/from additional sites;
(3) The Individual must be available to provide in-person care at the direction of each NHSC-approved
telehealth site, regardless of whether such sites are distant or originating sites; and
(4) If telehealth services are provided to patients in another State, the clinician must be licensed to
practice (including compacts) in both the State where the clinician is located (i.e., the distant site) and the
State where the patient is physically located (i.e., the originating site).
(5) In addition to the above requirements, Individuals obligated under the NHSC Loan Repayment Program
may receive NHSC service credit for telehealth services only if the originating site(s) and distant site(s) meet
the HPSA score requirements of their LRP contract (e.g., if the Individual's LRP contract requires service in a
HPSA scoring 14 or higher, both the originating site(s) and the distant site(s) must have associated HPSA
scores of 14 or higher).
3. Waive his or her right to any minimum salary or benefits.
4. Accept that he or she may not have malpractice insurance, including tail coverage, provided by the NHSC‐approved
service site(s) specified above. The Individual further agrees to obtain and maintain malpractice coverage throughout
the NHSC service period.
5. Except as provided in Paragraph 2.d.(4) (pertaining to telehealth), maintain a current, full, permanent,
unrestricted, and unencumbered health professions license in the State(s) in which the approved service site is
located, for the duration of the Individual’s NHSC service obligation.
6. Comply with the charging requirements set forth in Section 334 of the Public Health Service Act (42 U.S.C. § 254g),
including the obligations to treat all patients regardless of ability to pay, to use a sliding fee scale and charge
reduced fees or no fees for patients with incomes at or below 200 percent of the poverty level, and to accept
reimbursement under Medicare, Medicaid, and the Children’s Health Insurance Program.
7. Immediately report to the NHSC any changes in the Individual’s employment, including work location and work hours.
8. Submit In‐Service Verification Reports every 6 months of the service period, and such other documents as the
Secretary may require to evaluate the Individual’s compliance with NHSC service requirements.
9. Maintain practice records, including patient files, business/financial records, and appointment logs for the duration
of service under this Agreement and for at least three (3) years after expiration of this Agreement. The Individual
further agrees to allow NHSC representatives to conduct site visits to inspect the practice and its records, and to
make himself/herself and office staff available to answer questions as needed.
10. Operate the private practice consistent with generally accepted standards of practice for the Individual’s health
professions discipline and specialty.
11. Accept that, as a PPO provider, he or she is ineligible to fulfill his or her service obligation in half‐time clinical
practice.
12. Be liable to the United States for damages in accordance with the Individual’s NHSC Scholarship Program, NHSC Loan
Repayment Program, or NHSC Students-to-Service Loan Repayment Program Contract (as applicable) in the event of
breaching this PPO Agreement.
13. The following additional conditions:

___________________________________
Individual’s Signature

Page 3 – Private Practice Option Agreement (revised December 2018)

___________________
Date