Form 4 STAR LRP Employment Verification Form

OMB No. 0906-0058
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

SUBTANCE USE DISORDER TREATMENT & RECOVERY LOAN REPAYMENT PROGRAM
EMPLOYMENT VERIFICATION FORM

INSTRUCTIONS
As the Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP) point of contact, 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. For purposes of the STAR LRP full-time employment is defined as a minimum of 40 hours per week, for a
minimum of 45 weeks each service year. Of the 40 hours per week, a minimum of 36 hours must be spent providing direct treatment or recovery support
to patients with or in recovery from a substance use disorder at the STAR LRP -approved facility, during normally scheduled office hours. The remaining
four (4) hours per week may be used for clinical-related administrative, management or other activities. The 40 hours per week includes scheduled breaks.
Participants do not receive service credit for hours worked over the required 40 hours per week and excess hours cannot be applied to any other work
week. Time spent “on call” will not be counted toward the service obligation, except to the extent the provider is providing patient care during that period.
If the applicant provides clinical services at multiple STAR LRP -approved facilities, a separate Employment Verification request will be initiated and
must be submitted for each location. Your accurate and timely completion of this Employment Verification impacts this clinician’s eligibility for
initial and/or continued program support and benefits. For additional information regarding the employment verification process see the STAR LRP
Employment Verification FAQs.
If you require further assistance with completing the EV, or if you are not the STAR LRP point of contact, 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 LRP Facility Name:

STAR LRP Facility Name:

Street Address:

Street Address:

City:

State:

Zip Code:

State:

Zip Code:

STAR LRP Facility Name:

STAR LRP Facility Name:

Street Address:

Street Address:

City:

City:

State:

Zip Code:

City:

State:

Zip Code:

OMB No. 0906-0058
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration
APPLICANT INFORMATION
Is the

at

currently working, or will work as a

STAR LRP -approved service facility(s) you have listed above?
have a current, full, permanent, unencumbered, and unrestricted license to practice at this facility?

Does

EMPLOYMENT INFORMATION
When did

begin to practice and meet the STAR-LRP service requirements at?

Does/will

meet the STAR-LRP Clinical Practice Requirements for full-time participants?

Total hours

works per week at at the facility(s) per the STAR LRP Clinical Practice Requirements

SERVICE TYPE VERIFICATIONS
Does your organization or the entity with who you have an agreement to provide healthcare services at
ensure that
Does

?
provide services at

Does

Does

as a self-employed worker or independent contractor?

own or have a financial interest interest in

provide

or the organization with who you have an

an agreement to provide healthcare services at our facility provide

with malpractice insurance and tail

coverage (either commercially or through the Federal Tort Claims Act)?
Is

meeting the STAR LRP requirements for "direct treatment or recovery support for patients with or in
recovery from substance use disorder" at one of more of the following STAR-LRP approved facility types?
•
•
•
•
•
•
•
•
•
•

Federally Qualified Health Center (FQHC)
Federally Qualified Health Center (FQHC) Look-A-Alike
Community Mental Health Center (CMHC)
Community Outpatient Facility
Independent Group/Private Practice
Certified Rural Health Clinic
Indian Health Service (IHS) Tribal or Urban Indian
American Indian Health Facility
School-Based Clinic
State or Local Health Department

•
•
•
•
•
•
•
•
•

Free Clinic
Mobile Unit
Federal Bureau of Prisons (BOP)
Immigration Customs Enforcement Correction Facilities (ICE)
State Correctional Facility
Critical Access Hospital (CAH)
SAMHSA-certified Outpatient Treatment Programs (OTPs)
Office-based Opioid Treatment Facilities (OBOTs)
Non-Opioid Substance Use Disorder Treatment Facilities (SUD
Treatment Faciltiies)

OMB No. 0906-0058
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration
LICENSURE
What is the expiration date of this clinician's professional license?
What is the license number?
In which state or U.S. territory is this license registered?
The Substance Use Disorder Treatment and Recovery Loan Repayment Program Point of Contact
The responses and information provided above are true, accurate and complete to the best of my knowledge and belief.

Name - please print & include title

Email Address

Point of Contact - Signature

Date

For questions on how/where to submit this form please contact the Customer Care Center at: 1-800-221-9393.

Public Burden Statement: The purpose of this information collection is to obtain information through the Substance Use Disorder Treatment and Recovery
Loan Repayment Program(STAR LRP) that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the STAR LRP and to
obtain information for eligible facilities or sites. Clinicians interested in participating in the STAR LRP must submit an application to the STAR LRP through
the My BHW online portal. 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
is required to obtain or retain a benefit (Section 781 of the Public Health Service Act [42 U.S.C. § 295h]). The information is protected by the Privacy Act, but it
may be disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress,
the National Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Record
Notice 09-15-0037. Public reporting burden for this collection of information is estimated to average xx 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 13N82, Rockville, Maryland, 20857.