MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM

Transcription

1 MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM APPLICATION INSTRUCTIONS Applications are accepted and considered once a year on a date determined by the advisory committee. Applications for program participation are made jointly by a physician and an organization or institution (such as a hospital or clinic) in the community in which the physician wishes to practice. The application form contains sections for both the physician and the supporting organization/institution to complete. A separate loan information and verification form must be completed for each individual educational loan submitted for repayment consideration. Only verifiable medical education debt qualifies for repayment. Because the program will only assist with the repayment of loans related to medical education, applicants with refinanced or consolidated loans must satisfactorily identify each individual loan that is part of the consolidation, including the original loan dates and loan amounts. Medical education debt may include undergraduate education debt, but may not include debt incurred during residency training. A physician who qualifies is not guaranteed the maximum repayment amount. Program benefits allow up to a maximum of $100,000 in loan repayment benefits to be applied toward qualified medical education loans for full-time participating physicians over a one- to five-year period of service in an approved location. Proportionately reduced repayment amounts are available for physicians practicing less than full-time. The maximum eligibility period is five years and awards are not made retroactively. Physicians participating in a federal or Indian Health Service loan repayment program or while completing a federal or Indian Health Service (IHS) practice obligation are not eligible for MRPIP participation until completion of their federal or IHS eligibility period. The supporting institution/organization must include documentation explaining the need for assistance with physician recruitment and retention in their community, including at a minimum, a statement of 1) efforts made to recruit physicians over the past five years; 2) the number of physicians lost to retirement or relocation over the past five years; and 3) the reasons why recruitment will continue to be a problem for the community. A copy of the applicant s current curriculum vitae or resume must be included with the application materials. Applications are to be submitted to the following address: OFFICE/COMMISSIONER OF HIGHER EDUCATION MONTANA UNIVERSITY SYSTEM 2500 BROADWAY P O BOX HELENA, MT (406) (Phone) (406) (Fax) Further information regarding the program and application process may be obtained by contacting Laurie Tobol with the Office of the Commissioner of Higher Education at (406) or by at: ltobol@montana.edu.

2 -2- MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM APPLICATION FORM - SECTION 1 (TO BE COMPLETED BY PHYSICIAN) NAME: BIRTHDATE: SOCIAL SECURITY NO.: BIRTHPLACE: ADDRESS: HOME ADDRESS: HOME PHONE: BUSINESS ADDRESS: BUSINESS PHONE: HIGH SCHOOL GRADUATED FROM: (Name and Location) SCHOOL OF MEDICINE OR OSTEOPATHY ATTENDED: DATES YOU ATTENDED: WAS YOUR MEDICAL EDUCATION SUPPORTED THROUGH EITHER WWAMI OR WICHE? Yes No If yes, from which State: RESIDENCY EXPERIENCE: Dates: Specialty: Institution: Location: NAME OF DIRECTOR OF RESIDENCY PROGRAM: NAME ADDRESS PHONE NUMBER WORK EXPERIENCE SINCE LEAVING TRAINING: SPECIALTY BOARD CERTIFICATION: Yes No Date: LICENSED TO PRACTICE MEDICINE: Yes No State: HAVE YOU EVER BEEN SUBJECT TO DISCIPLINARY ACTION? Yes No If yes, please explain: HAVE YOU EVER HAD A PROFESSIONAL LICENSE SUSPENDED OR RESTRICTED? Yes No If yes, please explain:

3 PROFESSIONAL REFERENCES: -3- MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM APPLICATION FORM SECTION 1 CONTINUED NAME/TITLE ADDRESS PHONE NUMBER OUTSTANDING EDUCATIONAL INDEBTEDNESS:* NAME OF LENDING INSTITUTION MAILING ADDRESS PHONE NUMBER ACCOUNT NUMBER ACCOUNT BALANCE * Please complete a separate loan verification form for each loan being submitted for loan repayment. IS THE APPLICANT SITE A FEDERALLY DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA? Yes No Medical HPSA Score: HAVE YOU APPLIED FOR FEDERAL OR HPSA FUNDS? Yes No To Be Determined If yes, list your approval date and eligibility period: (Please submit a copy of your award letter as verification.) If no, indicate the date you will file an application, or if no filing is expected, please explain: NOTE: Federal repayment assistance may be available under the National Health Services Loan Repayment program. All MRPIP candidates are expected to apply for such benefits if the practice area/location qualifies. State and federal loan repayment benefits cannot be received concurrently; only qualified medical school loan debts not eligible for repayment under a federal loan repayment program are eligible for repayment under the MRPIP. Physicians participating in a federal or Indian Health Service (IHS) loan repayment program or while completing a federal or IHS practice obligation, are not eligible for MRPIP participation until completion or fulfillment of their federal or IHS eligibility period. Physicians must notify the Commissioner of Higher Education if and when participation in a federal or IHS loan repayment program begins. LOCATION OF PRACTICE: TYPE OF PRACTICE: PRACTICE IS EXPECTED TO BE: FULL-TIME OR PART-TIME DATE ON WHICH PRACTICE IS EXPECTED TO BEGIN: REASONS FOR CHOOSING THIS SITE FOR PRACTICE: I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE: (Signature of Physician) (Date)

4 -4- MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM APPLICATION FORM - SECTION 2 (TO BE COMPLETED BY SUPPORTING INSTITUTION) SUPPORTING INSTITUTION: ADDRESS: PHONE: FAX: CONTACT: (Name and Title) SERVICE AREA POPULATION OF SERVICE AREA: POPULATION/PHYSICIAN RATIO: SIZE OF LOCAL HOSPITAL: NAME/LOCATION OF HOSPITAL: DOES APPLICANT PHYSICIAN HOLD PRIVILEGES AT LOCAL HOSPITAL? IF NOT, AT WHAT HOSPITAL DOES APPLICANT HOLD PRIVILEGES? LIST ALL PRIMARY CARE PHYSICIANS PRACTICING IN THE COMMUNITY (Attach additional sheet if necessary): NAME TYPE OF PRACTICE CAN THE COMMUNITY DEMONSTRATE A HISTORY OF EXPERIENCING DIFFICULTY WITH RECRUITMENT AND RETENTION OF PRIMARY CARE PHYSICIANS? Yes No Supporting Institution/Organization: you must include documentation explaining the need for assistance with physician recruitment and retention in the community, including at a minimum, a statement of 1) efforts made to recruit physicians over the past five years; 2) the number of physicians lost to retirement or relocation over the past five years; and 3) the reasons why recruitment will continue to be a problem for the community. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE: (Signature of Institution Official) (Title) (Date)

5 LOAN INFORMATION AND VERIFICATION FORM THE MONTANA RURAL PHYSICIAN INCENTIVE LOAN REPAYMENT PROGRAM MONTANA UNIVERSITY SYSTEM OFFICE OF COMMISSIONER OF HIGHER EDUCATION 2500 BROADWAY HELENA, MT The following information must be provided for each loan you are submitting for repayment consideration under the Montana Rural Physician Incentive Program. Print clearly and completely to help expedite verification. Please note that incomplete information may delay verification of your loan. APPLICANT: Complete one copy of this form for each loan you are submitting for repayment consideration under the Montana Rural Physician Incentive Program. Please print clearly and be sure to complete all of Section A to expedite verification. UPON COMPLETION OF PART A, SEND THIS FORM TO YOUR LENDER TO COMPLETE THE VERIFICATION CONTAINED UNDER PART B and have them return the completed form back to you Attach a copy of the original loan agreement and current statement of account to the corresponding loan verification form (Part A and Part B) and SUBMIT WITH YOUR APPLICATION MATERIALS TO THE OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION (OCHE). LENDING INSTITUTION: PLEASE COMPLETE PART B ON THE NEXT PAGE OF THIS FORM AND RETURN TO THE APPLICANT IDENTIFIED IN PART A TO BE SUBMITTED WITH THEIR APPLICATION MATERIALS TO THE MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM. PART A (To be completed by Applicant) 1. NAME: (Last, First, Middle) 2. BIRTHDATE: 3. SOCIAL SECURITY NUMBER: 4. COMPLETE ADDRESS: (Street, P O Box, City, State, Zip) 5. TELEPHONE NUMBER: 6. NAME OF LENDING INSTITUTION: 7. TELEPHONE NUMBER: 8. FAX NUMBER: 9. LOAN ACCOUNT NUMBER: 10. FULL ADDRESS OF LENDING INSTITUTION: (Street, P O Box, City, State, Zip) 11. HAS THE LOAN BEEN SOLD TO ANOTHER LENDER OR PAYMENT PROCESSING CENTER? Yes No IF YES, INDICATE SECONDARY LOAN HOLDER/PAYMENT PROCESSING CENTER'S NAME AND FULL ADDRESS. 12. LOAN INFORMATION: Loan Account Number: Original Amount of Loan: Original Date of Loan: Current Balance/Date: 13. PURPOSE OF LOAN AS INDICATED ON LOAN APPLICATION: 14. TYPE OF LOAN (Stafford, Health Professions, etc.) FOR CONSOLIDATED UNDERGRADUATE AND GRADUATE EDUCATION LOANS: If you have consolidated your loans for undergraduate and graduate education costs, you must attach a copy of the loan documents for all health professions education costs that were consolidated into the new loan. WARNING: Any person, who knowingly makes a false statement or misrepresentation in this loan repayment transaction, fraudulently obtains repayment for a loan, or commits any other illegal action in connection with this transaction is subject to repaying any amount received from this program plus 8% interest. I have read this statement and understand its contents. CERTIFICATION BY APPLICANT: I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Commissioner of Higher Education for repayment of the medical education loans I have submitted with my application hereof, incurred solely for the costs of medical education, including reasonable living expense, at a school of medicine or osteopathy. I hereby authorize the financial institution named in Item 5 above to release all loan account information to the Montana University System, OCHE for purposes of my participation in the Montana Rural Physician Incentive Program from this point forward throughout the duration of my loan repayment program participation as necessary. SIGNATURE OF APPLICANT DATE

6 LOAN INFORMATION AND VERIFICATION FORM THE MONTANA RURAL PHYSICIAN INCENTIVE LOAN REPAYMENT PROGRAM PART B (To be completed by Lending Institution) The individual identified on the first page of this form has applied to participate in the Montana Rural Physician Incentive Loan Repayment Program and states that, to the best of his/her knowledge, the loan information provided is a bona fide legally enforceable commercial, state or government educational loan made for the purpose of meeting the borrower's costs of attending a school of medicine or osteopathy. Please verify this information according to your records by completing the information below. ACCOUNT NUMBER: ORIGINAL AMOUNT OF LOAN: (If this is a consolidation, please provide detail identifying the original loan amounts and loan dates for all loans consolidated.) ORIGINAL DATE OF LOAN: (If this is a consolidation, please provide detail identifying the original loan amounts and loan dates for all loans consolidated.) CURRENT LOAN BALANCE: LENDING INSTITUTION/LOAN SERVICER: (Name) (Street Address) (City, State, Zip Code) (Telephone) (FAX) (Federal Tax ID Number) (Required for Payment Processing) PERSON TO CONTACT REGARDING CURRENT LOAN BALANCE INFORMATION PRIOR TO SIX MONTH DISBURSEMENTS: (Name) (Department) (Telephone) COMMENTS: I hereby certify to the accuracy of the loan information contained on the reverse side of this form or as provided by the above notations and comments. SIGNATURE TITLE DATE PLEASE RETURN THIS FORM TO THE APPLICANT IDENTIFIED IN PART A ON THE PREVIOUS PAGE TO BE SUBMITTED WITH THEIR APPLICATION MATERIALS TO THE MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM. LOANVERF.doc