Loan Repayment Program for Child Psychiatry, DOs and MDs in family practice, pediatrics, and general internal medicine

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1 Lancaster Osteopathic Health Foundation Loan Repayment Program for Child Psychiatry, DOs and MDs in family practice, pediatrics, and general internal medicine 2015 Application Package Lancaster Osteopathic Health Foundation Loan Repayment Program 128 E. Grant Street, Suite 104 Lancaster, PA (717)

2 Application Instructions Application The application consists of: a) the three-page Application, Sections I-VI; b) the one-page Practice Site questionnaire; and c) the one-page Loan Information form. Required Documents In addition to the five pages described above which make up the application, the applicant must submit the following: 1. W-9 form (first page only) signed in blue ink; 2. Current resume or CV; 3. A copy of applicant s Pennsylvania Medical License; 4. Background and Biographical Statements narrative (page 2, Section IV of Application); 5. A balance statement from each lender showing the current loan balance, account number and lender s address (see Loan Information form); 6. A letter, addressed to the Lancaster Osteopathic Health Foundation from the applicant, authorizing the lenders to release financial information to LOHF (see Loan Information form); 7. A copy of the practice site s Sliding Fee Scale, policy and waiting room/lobby sign, if applicable (see Practice Site questionnaire); 8. The applicant s job description; and 9. A copy of the applicant s employment contract. Eligibility Psychiatrists and physicians who are practicing or finishing their residency or fellowship in the following specialties may apply, in order of LOHF priority: Psychiatry Child and Adolescent Family Practice (DO) General Pediatrics (DO) General Internal Medicine (DO) Family Practice (MD) General Pediatrics (MD) General Internal Medicine (MD) Applicants must work full-time, defined as a minimum of 40 hours/week at an eligible site. For all physicians, at least 32 of the 40 hours must be spent in direct patient care in an outpatient setting. All sites must be located in Lancaster County or serve primarily Lancaster County residents as patients. Instructions Application for Loan Repayment Two Pages I. Applicant Demographics

3 In this section, as all sections, every field is required. Under Race, more than one option may be selected. For Ethnicity, mark only one. The Total Medical School Debt is the sum of all existing medical school loans, i.e. current balances. II. Education Respond to all four sections, including dates of attendance. If you attended more than one medical school or undergraduate program, list only the one from which you graduated. III. Obligations No person with an existing obligation to a state or federal government can apply unless the obligation will be fulfilled prior to the time of loan repayment contract awards. This includes existing loan repayment programs in other states, National Health Service Corps loan repayment or scholar commitments, active military obligation, or employment contracts that impose a service obligation. IV. Background and Biographical Statements Address all items in 1-5 as provided on the application. Responses shall be put into separate documents and included with the completed application packet. V. Professional References List only two, including all contact information as requested. Corresponding letters of reference are not needed. VI. Certification and Acknowledgements The applicant signs and dates numbers 1 and 2. The Executive Director or practice site administrator signs and dates number 3. Practice Site One Page Complete one page for each practice site where the applicant is, or will be, practicing. All sections must be completed in their entirety, including information about the parent organization. Ex: If one is within a hospital-affiliated primary care clinic, then the hospital should be listed as the Parent Organization. If the site has a sliding scale fee, a copy of the scale, policy, and waiting room/lobby sign must be included with the application (see #7). The person completing the Practice Site questionnaire should be the office manager, billing manager, or similar staff. The applicant cannot complete the Practice Site information unless he or she is the practice owner. All fields are required, including the Certification at the bottom of the page. Loan Information One Page I. Applicant Information If the applicant has consolidated medical school loans with non-medical school loans, the original loan documents and the consolidation documents must be included. II. Lender Information For Total Medical School Debt, list the sum of all existing medical school loans. This should be the same as in Section I on the first page of the application. In the chart, complete one line for each loan acquired. If additional room is needed, provide the information on another sheet. A current balance statement from each lender/servicer must be attached. A letter addressed to the Lancaster Osteopathic Health Foundation, authorizing the lenders to release financial information to the Lancaster Osteopathic Health Foundation, must be included.

4 W-9 One Page When completing the W-9, use your name, home address, and social security number. Do not use the practice site information or Tax ID, even if you are the owner of the practice. Please sign the W-9 in blue ink. This eliminates confusion as to whether the document is an original or a copy. The W-9 is available for download at

5 Lancaster Osteopathic Health Foundation 2015 Application for Health Professional Loan Repayment LOHF use: Date Rec d: / / Directions: The application and corresponding narrative must be completed in their entirety. All fields are required. I. Applicant Demographics Name, Last: First: Middle: Home Address: City: State: Zip: Cell Phone: Home Phone: Home Primary Practice Site Name: Site Address: City: State: Zip: Current Employment Contract Start Date: End Date: Work Phone: Work Alternate Date of Birth: Languages spoken other than English: Current training loan debt: $ Are you a: U.S. Citizen Legal alien Neither- Explain: Ethnicity: (select one) Hispanic/Latino Non-Hispanic/Latino Race: (check all that apply) American Indian/Alaska Native Pacific Islander/Native Hawaiian Asian White/Caucasian Black or African American Other: Raised in Lancaster County, Pennsylvania? If yes, please provide years. Yes ( - ) No Pennsylvania License Number: Medicaid Provider Number: National Provider ID: Physician Specialty: Only physicians who are Board-certified/eligible in the following specialties are eligible for funding. Select all that apply. Child/Adolescent Psych Family Practice IM/Peds General IM General PED General Psych Are you a DO or an MD? DO MD If Resident, date Available to Practice: Are you Board Certified? Yes No Other Discipline Specialty: (Select one) Nurse Practitioner Certified Nurse Midwife Clinical Social Worker (LCSW) General Practice Dentist Registered Dental Hygienist Psychiatric Nurse Specialist

6 Physician Assistant Licensed Professional Counselor Marriage and Family Therapist Clinical or Counseling Psychologist Pharmacist Pharmacist II. Education Name of Medical School/ Health Professional Training: City: State: Dates of Attendance: through Graduation Date: Residency Program: City: State: Dates of Attendance: through Graduation Date: Any additional training programs: City: State: Dates of Attendance: through Completion Date: Previous participant in these programs? Check all that apply. National Health Service Corps (NHSC) Loan Repayment Program NHSC Scholarship Program Student/Resident Experiences & Rotations in Community Health (SEARCH) Not Applicable Have you also applied to the National Health Service Corps? Yes No No but plan to this year Credentials (required before beginning the program). List any states where you currently hold a license: Note any licensure restrictions: III. Obligations Note: All applicants who have an outstanding contractual obligation for health professional service to the Federal Government (e.g. an active military obligation), a State (e.g. Loan Repayment or Scholarship Program) or other entity are ineligible to participate in the LOHF loan repayment program unless that service obligation will be completely satisfied before a loan repayment contract with LOHF would begin. Be aware that certain bonus clauses in employment contracts may impose a service obligation. 1. Do you have an existing service obligation? Yes No If Yes, complete the following: Name/ Description of obligation: Contact Person: Telephone: Completion Date: Terms of obligation: Are you in default of this obligation? Yes No 2. Are you delinquent in the payment of any child support obligation? Yes No Individuals delinquent in child support obligations are not eligible to participate in this program.

7 IV. Background and Biological Statements On separate document, respond to all of the following requests (label each section to correspond with the numbers and letters below): 1. Describe your interest and experience in serving children and families who have behavioral health needs. 2. Provide two-four professional and personal goals as they related to your participation in the Lancaster Osteopathic Health Foundation loan repayment program. 3. Describe student, volunteer or work experience with medically underserved populations (e.g. Federally Qualified Health Centers, free clinics, public health departments, rural health clinics)/ describe your experience working in children s behavioral health. a. Location b. Start and end dates for each student/work experience c. Number of hours per week spent on the student/work experience d. Brief description of the experience e. The knowledge, skills, or abilities gained from the experience f. Community effort which lead to improved delivery of health services to underserved populations g. Total number of years/months as a clinician providing care to underserved populations h. Published articles related to this work i. Awards for community efforts 4. Share language skills (including level of proficiency), if any, that the applicant uses or will use to provide services to the patient population at the practice site. 5. Provide any additional knowledge, skills, and abilities that will be incorporated into your practice to improve the delivery of health services to the population of the community site. Please include any specific experience, knowledge, skills, or abilities in providing care to children and families. Consider the values, beliefs, and practices of the patient population. V. Professional References (List two) 1. Name: Title: Address: Telephone: 2. Name: Title: Address: Telephone: VI. Certification and Acknowledgements 1. I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that any willfully false representation is sufficient cause for rejection of this application. Applicant s Signature Date

8 2. I acknowledge that I have read the Application Information and understand that if selected for a loan repayment contract, I will be bound to practice for a minimum of two years. I also understand that failure to uphold the requirements of a loan repayment contract could result in significant financial consequences. Applicant s Signature Date 3. As an administrator with (practice site), I understand that the applicant, if selected for the Lancaster Osteopathic Health Foundation loan repayment program, has a minimum two-year commitment to the above-named site. Furthermore, I acknowledge that LOHF loan repayment program participants must work a total of 40 hours per week at eligible sites, of which no more than 8 can be spent in administrative duties. Executive Director or Site Administrator Signature Date

9 Practice Site Directions: Complete one Practice Site information page for each site where the applicant practices or will practice. This page cannot be completed by the applicant unless he or she is the owner of the practice. 1. Clinician (applicant) Name: 2. Practice Parent Organization Name: Parent Organization Address: Parent Organization Phone: Parent Organization Fax: 2. Practice Site Phone: Practice Site Fax: 3. List hours per week the clinician will practice serving children at each practice site. List a primary location first: Practice Site Name/ Address, City, State, Zip Hours/ Week 4. Does this practice participate in the Pennsylvania Medicaid program? Yes No If yes, please complete: a) Total number of Medicaid claims paid for the most recent 12 months: b) Total number of patient visits for the same period: c) Percent of the practice comprised of Medicaid patients: d) Practice Site s Medicaid number: 5. Does the practice accept new Medicaid patients? Yes No 6. Does the practice provide services regardless of the patient s ability to pay? Yes No 7. Does the practice use a sliding fee scale for patients with incomes below 200% of the Federal Poverty Guidelines? Yes No If yes, include a copy of the sliding fee scale with the application. 8. What percent of the patients are racial and ethnic minorities? % 9. Is this practice a not-for-profit entity? Yes No 10. Site Contact Person if Applicant is awarded Loan Repayment: Name of Contact: Phone: Certification: I hereby certify that the information provided above is correct to the best of my knowledge, and can be verified with patient payer data and billing records. Printed Name of Person Completing Survey Title Date Signature of Person Completing Survey Phone

10 Loan Information Directions: Please list only the loans you are requesting to be paid, i.e. loans taken for the health professions training which enabled you to become eligible for this program. For each loan listed, attach a current statement from the lender showing the balance. Section I: Applicant Information Name (Last, First, MI): Home Address: City, State, Zip Code: Telephone Number: Have you consolidated your loans for undergraduate costs with medical school loans or health professions training program loans? Yes No If yes, attach copies of the loan documents, which reflect the new consolidated loan. Section II. Lender Information This program pays for the educational costs for a medical degree, or the training costs for the primary care and mental health professions as listed on page 1 of the application. If loans have been consolidated, a determination will be made of the proportion of the consolidation loans that will be paid for a successful applicant. Only Institutional or Government loans are eligible including Stafford, SLS, HEAL, Perkins, and others. Loans from individuals are not eligible. Total health professions training loan debt (total of column E): $ A Award Year B Disbursement Date C Holder/ Servicer of Loan D Original Loan Amount E Current Balance F Date of Balance G Projected Payoff Date Totals 0 0 Are any parts of the loan(s) listed above being paid by another organization? Yes No If yes, specify the amount being paid for applicable loans, the name of the organization, and the terms, including any obligations by the applicant. Amount: $ Payer: Terms: Section III: Certification I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that any false representation is sufficient cause for rejection of this application. Signature Date

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