4 Private Practice Option Form

OMB Number: 0915-0127

Expiration Date: xx/xx/xxxx

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, or NHSC Students to Service Loan Repayment Program), 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 Phone

The Secretary agrees to:

1. 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.

2. 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.

3. 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.

4. 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

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.

1. 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 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 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 (limited to 4 hours per week).

2. For obstetricians/gynecologists, family practice physicians who practice obstetrics on a regular basis, 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 4 hours per week).

3. For physicians (including psychiatrists), nurse practitioners, physician assistants, and certified nurse‐ midwives serving in an Indian Health Services (IHS) Hospital or Critical Access Hospital (CAH), at least 24 of the minimum 40 hours per week must be spent providing patient care in the hospital-affiliated outpatient ambulatory care setting(s) at the approved service site(s), during normally scheduled office hours. Of the minimum 24 hours per week of patient care, teaching shall not exceed 8 hours per week. The remaining 16 hours of the minimum 40 hours per week must be spent providing patient care at the CAH or IHS Hospital that is an approved service site or in the hospital-affiliated outpatient ambulatory care setting(s) at the approved service site(s), providing patient care in the hospital-affiliated skilled nursing facility or swing bed unit, or performing clinical-related administrative activities (limited to 4 hours per week).

4. For full-time behavioral and mental health providers, at least 20 of the minimum 40 hours/week must be spent providing patient care at the approved service site(s). Of the minimum 20 hours spent providing patient care, no more than 8 hours/week may be spent in a teaching capacity, in an alternate setting as directed by the approved site(s), or performing clinical-related administrative activities (limited to 4 hours per week). The remaining 20 hours/week may be spent providing patient care at the approved service site(s) or performing service as a behavioral or mental health professional in schools or other community-based settings when directed by the approved site(s). If working in an IHS Hospital or CAH (only applies to psychiatrists or physician assistants and nurse practitioners with specialized training in mental health), at least 24 hours/week must be spent providing patient care in the IHS or CAH-affiliated outpatient clinic. Of the minimum 24 hours spent providing patient care, no more than 8 hours per week may be spent in a teaching capacity. The remaining 16 hours/week are spent providing patient care at the IHS Hospital or CAH or the IHS or CAH-affiliated outpatient clinic, providing patient care at the hospital-affiliated skilled nursing facility or swing bed unit, or performing clinical-related administrative activities (limited to 4 hours/week).

5. 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 NHSC-approved 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 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 requirements of their LRP contract.

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. 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 Date

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/xxxx. 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].