New Application for Individual Providers

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1 Professional Discipline Eligibility New Application for Individual Providers The first set of questions in this application will determine whether you are eligible for participation in this loan repayment program under federal and state program requirements. Before you begin, please review your eligibility factors, including hourly requirements, at You may also wish to learn more about expanded eligibility as it relates to clinical pharmacists and part time providers. After your basic eligibility is confirmed, you will be prompted to enter specific information about yourself. Your responses within the application help determine your eligibility for the program. If you are determined to be ineligible, you will not be able to complete this application. Please note that applying for loan repayment through the Colorado Health Service Corps is a two part process. You are entering the individual provider loan repayment application now. The site where you work must also be designated as an approved loan repayment site. Please check the approved sites list on or contact an administrator at your organization to verify that a CHSC site application has been submitted and approved. If this has not been done, an administrator from your site must complete the Colorado Health Service Corps Site Application before you can apply. At the conclusion of this application, you will be required to upload the following electronic documents: your resume or curriculum vitae current loan statement(s) from each educational lender two letters of support a personal statement These documents are required and must be submitted through this online application for you to be considered in the applicant pool. Please do not use your browser's back button during this application. Select your health professional discipline. You must be licensed in Colorado, in your field, at the time of application. Physician Physician Assistant

2 Advanced Practice Nurse (master's or doctoral degree) Mental or Behavioral Health Professional (master's or doctoral degree) Clinical Pharmacist (PharmD degree) ne of these professional disciplines Please select your mental health credential. PhD Clinical or Counseling Psychologist PsyD Clinical or Counseling Psychologist LCSW Licensed Clinical Social Worker (master s or doctoral degree in social work) LPC Licensed Professional Counselor (master s or doctoral degree; major study in counseling) LMFT Licensed Marriage and Family Therapist (master s or doctoral degree; major study in therapy) Other mental or behavior health discipline Please select your nursing credential. CNM Certified Nurse Midwife NP Nurse Practitioner NP Mental Health Nurse Practitioner Other nursing credential Please select your physician credential. DO Doctor of Osteopathic Medicine MD Doctor of Allopathic Medicine Please select your professional specialty. Family Medicine Geriatrics Internal Medicine Obstetrics and Gynecology

3 Pediatrics Psychiatry Child Psychiatry Other specialty Practice Characteristics Eligibility Please select your preferred type of service obligation. Detailed hourly requirements are available at Full time Part time Do you regularly practice at least 40 hours per week with at least 32 hours in direct clinical patient care? Do you regularly practice at least 20 hours per week with at least 16 hours in direct clinical patient care? Is your direct clinical care provided in an outpatient primary care setting? This program broadly defines primary care to include general medical, obstetrical, oral, mental and behavioral health care. Primary care is provided by health professionals specifically trained for and skilled in comprehensive first contact and continuing care for people with any undiagnosed sign, symptom or health concern not limited by problem origin, organ system or diagnosis. Primary care includes diagnosis and treatment of acute and chronic illnesses, health promotion, disease prevention, health maintenance, counseling and patient education in a variety of health care settings., but I work in a state mental health hospital or correctional facility

4 How is your practice incorporated? nprofit (usually a 501(c)3 nonprofit corporation) Private (an independent practice for profit) Correctional Facility (state or federal only) Public (usually a governmental authority, hospital district, or division of local, state or federal government) State Mental Health Hospital Select the payor types your practice regularly accepts. This loan forgiveness program requires that a provider accept public insurance and offer a sliding fee scale to low income, uninsured patients. Child Health Plan+ Medicaid Medicare Private insurance Uninsured Does your practice see patients 18 years old and younger? Does your practice see pregnant women? Does your practice see patients 65 years old and older?

5 For patients who are both uninsured and low income, does your practice offer reduced clinic fees on a sliding scale? te: Bad debt write off policies do not constitute a sliding fee scale. Sliding discounts must extend to at least all those below 200% of federal poverty. Health professionals who practice in a state or federal correctional institution may be eligible for the Colorado Health Service Corps if the facility is medium or higher security and has an active Health Professional Shortage Area designation. Does your site have this specific designation for correctional facilities, as designated by the US Secretary of Health and Human Services? Visit for more information. Health professionals who practice in a state mental health hospital may be eligible for the Colorado Health Service Corps if the facility is designated to have its own Mental Health Professional Shortage Area. Does your site have this specific designation for state mental health hospitals, as designated by the US Secretary of Health and Human Services? Visit for more information. Is your practice located in a Mental Health Professional Shortage Area as designated by the US Secretary of Health and Human Services? Answer "" if you practice at a federally qualified community health center. If you do not practice at a federally qualified community health center, visit for more information. Unsure Is your practice located in a Primary Care Health Professional Shortage Area as designated by the US Secretary of Health and Human Services?

6 Answer "" if you practice at a federally qualified community health center. If you do not practice at a federally qualified community health center, visit for more information. Unsure Your response indicates that you do not meet the hourly requirements for the type of service obligation you selected. Are you currently seeking a position where you will provide outpatient care to underserved patients? How important is loan repayment to your ultimate decision on where to practice? t at all Important Very Important Importance If you are selected for an award, you must submit proof of qualifying employment at an approved site within 120 days of the closure of an application cycle. General practice eligibility characteristics include: Practice in an eligible professional discipline Clinical practice location in a Health Professional Shortage Area Ambulatory outpatient setting Primary care clinical services Public or nonprofit employer Care for publicly insured (Medicaid, Medicare, CHP) Care for uninsured and/or low income patients according to a sliding fee scale For detailed site eligibility requirements, visit Personal Information Enter your full legal name. First Middle

7 Last What is your birth date? (mm/dd/yyyy) Are you a citizen of the United States? What is your gender? (optional) What is your race? (optional) Residential address Address City State Zip Code Primary phone number Primary Phone

8 Alternate phone number (optional) Alternate Phone Licensure Do you have an active, unrestricted license to practice in the state of Colorado? License License number Date of first issue (mm/dd/yyyy) Date of expiration (mm/dd/yyyy) You responded that you do not have an active, unrestricted license to practice in Colorado. Please explain. Please tell us about your medical residency program. Name City State Supervisor name Date of completion (mm/dd/yyyy)

9 Applicant Training Information Recruitment Are you registered with the Colorado Provider Recruitment (CPR) program of the Colorado Rural Health Center? Have you seen the Mission Driven Careers website from the Colorado Community Health Network (CCHN)? For opportunities in rural and urban underserved areas, please visit For opportunities in Federally Qualified Health Centers, please visit Links will open in a new window. Professional training experiences Did you graduate from a health professional training program in Colorado? Did you participate in a rural track while you were in school? Did you participate in a community health track while you were in school? Did you participate in a student health professional development program prior to beginning your professional training program (i.e. in junior high, high school or as an undergraduate)? Which Colorado school did you attend to receive your health professional training? From which rural track or emphasis training program did you graduate? From which community health track or emphasis training program did you graduate?

10 Briefly describe the health professional training experience(s) you had prior to selecting your professional degree program. Do you have other degrees unrelated to your professional training or the prerequisites for your professional degree program? If so, list the degree, subject and date of completion below. If none, please continue to the next page. One baccalaureate degree as a prerequisite for master's or doctoral level programs is considered related to your professional degree. Degree (bachelors, master's, doctorate) Subject Area or Major Date of Completion Are you capable of delivering health care services in a language other than English? In which languages other than English are you able to deliver health care services? Language 1 Language 2

11 2.0 Questions How many years have you been licensed in your current discipline? Are you currently involved with any community level prevention activities (e.g. working with your local public health agency on a population health problem)? Please provide a brief description of your community level prevention activities. Are you currently serving as a preceptor for student learners or a supervisor for a mental health professional seeking licensure? Please indicate the number of learners you precept or supervise each year. Please indicate the type of learners that you precept or supervise. With which academic training programs are you and the students affiliated?

12 Please indicate how interested you are in participating in the following activities. Very Interested Somewhat interested Neutral Somewhat disinterested Very disinterested Community prevention activities Precepting or supervising a student If you have any additional comments about your level of interest or current activities, please state them here. Employer Is your employer different than the physical site where you practice? Employer Information Please enter information for your EMPLOYER. Name of organization Main administrative address City Zip code County Phone

13 Site administrative contact Contact title Contact address Please enter information for your primary PHYSICAL PRACTICE LOCATION. Name of organization Name of site, if applicable Clinical practice address Clinical practice city Clinical practice zip code Clinical practice county Phone Employment start date (mm/dd/yyyy) Number of years in position Average weekly hours Comments (optional) Please enter contact information for your current direct supervisor. Name Phone number Practice Details

14 Are you routinely scheduled to practice at any other clinic site, for any other employer, or in a non primary care discipline (e.g. emergency medicine) during a typical week? If you are routinely scheduled to practice at any other clinic site, for any other employer, or in a non primary care discipline, please explain. If you attend in a hospital in addition to your outpatient practice, how many hours per week do you spend following up with your own patients at the hospital? Enter "0" if you do not attend in a hospital. Service Obligations Have you ever participated in a program that provided a specific practice incentive, such as loan repayment, in exchange for an employment obligation? If yes, indicate below. Colorado Rural Health Center, Colorado Rural Outreach Program (CROP) Indian Health Service National Health Service Corps Signing bonus with your employer that obligates you to a period of work Primary Care Loans (HRSA) Other Applied Accepted Currently serving an employment obligation t applied, or accepted When does or did your last employment/service obligation end (mm/dd/yyyy)? Competing service obligations from other incentive programs are not permissible. You must have completed all other service obligations prior to beginning a new service obligation through this program.

15 Educational Loan Debt Information In the following sections, enter lender information for all of your qualified educational loan debt. Qualifying educational loans include government and commercial loans for actual costs paid for tuition and reasonable educational and living expenses related to your undergraduate and graduate education. The debt must be associated with a degree in the health profession in which you will satisfy your service obligation. Educational loan debt associated with other post secondary degrees, unrelated to your health professional degree, is ineligible for loan repayment and should not be entered in this application. Primary Care Loans granted by the Health Resources and Services Administration are ineligible for repayment. Have you ever consolidated your educational loan debt? Have you consolidated your educational loan debt with other debts not associated with your education? Lender Information Enter the names of each of your educational lenders/loan servicing companies. (Example: Nelnet, Sallie Mae, FedLoan Servicing, etc.) Please note: some lenders may service several loans in one account, so please only list the lender or servicing company, and not every loan within the same lender or servicing company. Lender 1 Lender 2 Lender 3 Lender 4 Lender 5

16 Enter your total current educational loan balance for all lenders. Reference Documents On the next two pages, you will upload electronic documents including your resume/curriculum vitae and current loan statements from each lender you listed in the previous section. These documents are components of a complete loan repayment application and must be uploaded electronically for your application to be considered. The system will accept several file types, but PDF FORMAT IS PREFERRED. Please name your files with the type of file and your last name. Example: "CV Smith" or "Loan statement Jones" INCLUDE YOUR LAST NAME IN THE FILE NAME OF ALL UPLOADED DOCUMENTS. If you do not have electronic versions of all of the documents you need to upload, you can exit the application now and return to this point at any time up until the application deadline to complete your submission. To return to an application in progress, visit and click on the "application in progress" link to revisit your application. Upload your current resume or curriculum vitae. Please note: the upload feature may take several seconds to load. Upload current loan statements from each educational loan debt holder. Statements must include your name, the lender's contact information, and current balance. Please do NOT upload printouts from the National Student Loan Data System (NSLDS) or a credit report.

17 Please enter contact information for two people who will write your letters of support. One of your references must come from your direct supervisor. The other can come from someone who is in a position to evaluate your clinical skills and has the authority to speak on behalf of your organization. Suggestions of a second reference writer include: chief clinical officer (medical/dental/nursing/social work, etc.) executive director or chief executive officer clinic/practice/program manager human resources manager If you have been working at your current site for less than 6 months, you may choose to request a letter from a previous employer, faculty member from your health professional training program, or supervisor during a clinical rotation in a rural or underserved location. Based on the information you provide below, each person will be ed a link to complete a confidential online form that will be associated with your application. The letter of support form can also be accessed directly on our website. Name of reference 1 for reference 1 Name of reference 2 for reference 2 Enter a personal statement describing your interest in and commitment to serving the underserved people of the community where you practice (or intend to practice). Limit your essay to 500 words. Please clearly address each of the following points: 1. Your background, such as whether your grew up in an underserved and/or in a rural community, and your commitment to practice in a shortage area and/or serve vulnerable populations 2. What led you to a career in a health profession 3. Your education and training (include projects and skills related to serving underserved populations) 4. The patient population to which you provide services and a description of how you, as a health care provider, will address the disparities and/or improve the health outcomes of this specific patient population (for example: community outreach/education, support groups, research, etc.)

18 5. Your plans for further practice once your loan repayment service obligation is complete, should you be awarded Application Feedback How easy or difficult was it to complete this application? (optional) Very Easy Easy Somewhat Easy Neutral Somewhat Difficult Difficult Very Difficult Difficulty Please enter any feedback you may have about improving this application process. (optional) How did you learn about the Colorado Health Service Corps loan repayment program? (optional) Certification and Submission

19 Please include contact information for your organization's Human Resources representative. If your organization doesn't have an HR department, please include your CEO/Executive Director/Superintendent's information. Name Title Address Phone IMPORTANT APPLICATION NOTICE Your application must be submitted in its entirety, with all supporting documentation, prior to the end of the application period. Incomplete applications cannot be considered. By re entering your user name and password below, you are submitting your final application and affirming that all statements are true and accurate to the best of your knowledge. Any material false statement will disqualify you permanently from consideration in the current and any future award cycle. Should a material false statement be discovered after an award is made, your contract may be considered in default and may result in significant penalties. By submitting this application, you are authorizing representatives of the Primary Care Office at the Colorado Department of Public Health and Environment to contact your educational institutions, employers, professional licensing boards, lenders, and those who wrote your letters of support to verify the accuracy of the information contained in your application. You are also authorizing the Primary Care Office to conduct a background check on you using publicly available records. If selected for an award from this program, you will enter into a minimum 36 month contract with the state of Colorado, which will require continuous practice at the specified clinical address. You will be required to maintain all attributes of your practice that make you eligible to receive an award during your full term of service. Failure to do so may cause your contract to go into default, which will result in severe penalties. You must re enter your user name and password below to validate and submit your complete application. Username ( ) Password Date of Submission (mm/dd/yyyy)

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