Form 4 STAR LRP Employment Verification Form

OMB #: 0906-0058

Expiration Date: xx/xx/xxxx

INSTRUCTIONS

As the Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP) Point of Contact (POC), your assistance is needed to verify the employment and scope of practice for the applicant. Your responses must be based on the clinician’s current employment and clinical services provided at the specific STAR LRP-approved facility.

If the applicant provides clinical services at multiple STAR LRP-approved facilities, a separate Employment Verification (EV) request will be initiated and must be submitted for each location. Your accurate and timely completion of this EV impacts this clinician’s eligibility for initial and/or continued program support and benefits. For additional information regarding the employment verification process see the Substance Use Disorder Treatment and Recovery Loan Repayment Program Employment Verification FAQs.

If you require further assistance with completing the EV, or if you are not the STAR LRP POC, please contact the Bureau of Health Workforce (BHW) Customer Care Center, at 1-800-221-9393 (TTY: 1-877-897-9910), Monday-Friday (except Federal holidays), 8:00 am to 8:00 pm ET.

Participant Name:

Discipline and Specialty _

STAR Facility Name: Click or tap here to enter text.	STAR Facility Name: Click or tap here to enter text.
Street Address: Click or tap here to enter text.	Street Address: Click or tap here to enter text.
City: Click or tap here to enter text.	City: Click or tap here to enter text.
State, Zip code: Click or tap here to enter text.	State, Zip code: Click or tap here to enter text.

STAR Facility Name: Click or tap here to enter text.	STAR Facility Name: Click or tap here to enter text.
Street Address: Click or tap here to enter text.	Street Address: Click or tap here to enter text.
City: Click or tap here to enter text.	City: Click or tap here to enter text.
State, Zip code: Click or tap here to enter text.	State, Zip code: Click or tap here to enter text.

APPLICANT INFORMATION

Is the (Insert Applicant Name) currently working, or will work as a (Insert Applicant Discipline) at (Insert Facility Name) STAR-LRP approved service Facility (s) you have listed above?

Does (Insert Applicant Name) have a current, full, permanent, unencumbered, and unrestricted license to practice at this Facility?

EMPLOYMENT INFORMATION

When did (Insert Applicant Name) begin to practice and meet the STAR LRP service requirements at (Insert Facility)? Click or tap to enter a date.

Does/will (Insert Name) meet the STAR LRP Clinical Practice Requirements for full-time participants?

Total hours (Insert Name) work per week at the Facility(s) per the STAR LRP Clinical Practice Requirements. Click or tap here to enter text.

SERVICE TYPE VERIFICATIONS

Does your organization or the entity with who you have an agreement to provide healthcare services at (Insert Facility Name) ensure that (Insert Applicant Name)?

Does (Insert Applicant Name) provide services at (Insert Facility Name) as a self-employed worker or independent contractor?

Does (Insert Applicant Name) own or have a financial interest in (Insert Facility Name)?

Does (Insert Facility Name) provide (Insert Applicant Name) or the organization with who you have an agreement to provide healthcare services at your facility provide (Insert Applicant Name) with malpractice insurance and tail coverage (either commercially or through the Federal Tort Claims Act)?

Is [Applicant Name] meeting the Substance Use Disorder Treatment and Recovery(STAR) Loan Repayment Program (LRP) requirements for “direct treatment or recovery support of patients with or in recovery from substance use disorder” at one or more of the following STAR-LRP approved, facility types? *

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Federally Qualified Health Center (FQHC)	Free Clinic
Federally Qualified Health Center (FQHC) Look-A-Like	Mobile Unit
Community Mental Health Center (CMHC)	Federal Bureau of Prisons (BOP)
Community Outpatient Facility	Immigration Customs Enforcement Correction Facilities (ICE)
Independent Group/Private Practice	State Correctional Facility
Certified Rural Health Clinic	Critical Access Hospital (CAH)
Indian Health Service (IHS) Tribal or Urban Indian	SAMHSA-certified Outpatient Treat Program (OTPs)
American Indian Health Facility	Office-based Opioid Treatment Facilities (OBOTs)
School-Based Clinic	Non-Opioid Substance Use Disorder Treatment Facilities (SUD Treatment Facilities)
State or Local Health Department

LICENSURE

What is the expiration date of this clinician’s professional license? Click or tap to enter a date.

What is the license number? Click or tap here to enter text.

In which state or U.S. territory is this license registered? Click or tap here to enter text.

N A TIO N A L P R A C T I T I O N E R D AT A B A N K (N P D B )

Has your facility reviewed the National Practitioner Data Bank (NPDB) for this employee?

Date of the last NPDB query?

Click or tap to enter a date.

Wan adverse action reported?

The Substance Use Disorder Treatment and Recovery (STAR) LRP Point of Contact (POC)

^{The responses and information provided above are true, accurate and complete to the best of my knowledge and belief.}

Name – please print & include title STAR LRP Point of Contact – Signature

Email Address Date

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA program participant, program operations, and applications. In addition, these data will facilitate the ability to demonstrate alignment between BHW discretionary programs and the Substance Use Disorder Treatment and Recovery Loan Repayment and the Pediatric Specialty Loan Repayment programs. 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 0906-0058 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit Section 781 of the Public Health Service Act (42 U.S.C. § 295h) and Section 775 of the Public Health Service Act (42 U.S.C. § 295f). Public reporting burden for this collection of information is estimated to average xx hour 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].

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