Massachusetts Loan Repayment Program (MLRP) for Health Professionals Application Document Checklist June 2015 update

Transcription

1 Document Checklist June 2015 update Application is open from March 1st July 31 st Applicant and Employer must read the MLRP guide before completing this application at: Component A & C Applications: Please use this checklist to ensure your application is complete. Incomplete applications will not be reviewed. Health Professional Information Forms completed and signed by the health professional/applicant Employer Information Forms completed and signed by appropriate employer representative Payor Mix Information Form ( not applicable for correctional facilities) Health Professional's Qualifying Loan Statement(s). Health Professional s Pay Stub Standard Contract Form W-9 Form (Verification of Taxation Reporting Information) Electronic Payment Form (include voided check) Essay Copy of the health professional s current resume or curriculum vitae Copy of the health professional s current Massachusetts professional license Support letter from the practice site (When practice site is different from hiring employer organization a letter of support is required from the practice site) Component A & C Applications: (not required for FQHC applicants) Copy of non-profit or not-for-profit documentation for the health care organization/employer or practice site A copy of your practice site s sliding fee scale and policy. Your site s sliding fee scale should reflect current federal poverty guidelines. Current federal guidelines can be found here: Component A Applications: Proof of U.S. citizenship for the health professional (provide a copy of passport or birth certificate) Component C Applications: Either proof of U.S. citizenship (copy of passport or birth certificate) OR proof of legal residency (provide a copy of both sides of the permanent resident card) Documentation that greater than 30% of the patients served by the site are located in HPSAs or MUAs (not required for FQHC applicants) Application Submission Information: Please submit ONE completed original application. Use BLUE ink for all signatures. Please be sure to check off each applicable Document Checklist item. Submit documents in the order that they appear on the checklist. Your completed Document Checklist should be the first page to your application. Keep a copy of the entire application for your records. Mail to: Nicole Watson MDPH Health Care Workforce Center 250 Washington Street, 5 th Floor Boston, MA

2 Health Professional Information Form Application is for: Component A Component C Name: (First) (Middle Initial) (Last) Home Address: Street City Zip Code Residence prior to health professional education: City State Sex: M F Other Decline to answer Preferred Phone #: Work Phone #: Preferred Ethnicity: Are you Hispanic/Latino/Spanish? Yes No Decline to answer What race(s) do you most identify with? Check all that apply: Asian White Native Hawaiian/Other Pacific Islander Black American Indian/Alaskan Native Decline to answer Section B: Professional Information Profession: (circle one) Applicants must have completed a course of study required to practice independently without supervision. CNM Certified Nurse-Midwife DD General Dentist (D.D.S. or D.M.D.) DH Dental Hygienist DO* Doctor of Osteopathic Medicine HSP Health Service Psychologist (Ph.D. or equivalent; Clinical & Counseling) LADC 1 Licensed Alcohol and Drug Counselor (Master s level) LiCSW Licensed Clinical Social Worker (master s / doctoral degree in social work) LPC Licensed Professional Counselor MD* Doctor of Allopathic Medicine MFT Marriage and Family Therapist (master s / doctoral degree with a major study in marriage and family therapy) MHC Mental Health Counselor (master s / doctoral degree with a major study in counseling) NP Ω Primary Care Certified Nurse Practitioner PA Ω Primary Care Physician Assistant PD Pediatric Dentist PharmD Pharmacist PNS Psychiatric Nurse Specialist RN Registered Nurse * Family Medicine (& Osteopathic General Practice), Internal Medicine; Pediatrics; Ob-Gyn; Geriatrician; Psychiatrist Ω Adults; Family; Pediatrics; Psychiatry/Mental Health; Geriatrics; Women s Health Specialty: (e.g. Family Medicine) Board Certified? Yes No Other professional certification(s): School attended for health professional training: Name of residency training program: Undergraduate college or university: Section C: Employment Information Year of graduation (YYYY): Date of completion (MM/YYYY): Year of graduation (YYYY): Practice Site Name: Practice Site Address: Street City Zip Code Starting Date of Employment: Please indicate the # of hours you are scheduled to work per week: hrs/wk 1 of 2 Health Professional Information Form

3 Health Professional Information Form In addition to English, indicate language(s), you speak with sufficient fluency to provide adequate health care: How did you hear about the program? Massachusetts Department of Public Health/Primary Care Office Website Residency Employer Colleague Presentation at College / University Internet Search Other Have you previously received award(s) from the MLRP? Yes No Do you have a current commitment to any of the following programs: Yes No College/University Career Services *Please indicate in months the time commitment remaining. MLRP: Yes No Time Commitment Remaining: Mass League of Community Health Centers: Yes No Time Commitment Remaining: National Health Service Corp: Yes No Time Commitment Remaining: UMass Learning Contract: Yes No Time Commitment Remaining: Kraft Family National Center for Leadership & Training in Community Health: Other: Yes No Time Commitment Remaining: Provide affirmation of the eligibility criteria by initialing the following items: Time Commitment Remaining: Statement Affirmation (Initials) I, the applicant, am a United States Citizen (required for A; either US Citizen or legal permanent resident is required for C). I, the applicant, am a legal permanent resident (required for "C" if not a US Citizen). I have a current and non-restricted license to practice in the Commonwealth of Massachusetts, appropriate for the health profession discipline. I agree to provide primary care services to any individual seeking care and will not discriminate on the basis of the patient s ability to pay for care or on the basis that payment for care will be made pursuant to public payor programs such as: Medicaid/MassHealth, the State Children s Health Insurance Program, Commonwealth Care Programs, and/or through the sliding fee scale. (refer to Payor Mix section) I do not have a judgment lien against my property for a debt to the United States. DECLARATION: This Declaration form must be signed by the Health Professional Applicant All of the information on this application is truthful and accurate. I understand that knowingly submitting false information will void this application and may be considered a breach of my Massachusetts Loan Repayment Program (MLRP) for Health Professionals contract. I agree to sign a contract with the Massachusetts Department of Public Health/Primary Care Office to provide two years of full-time service or equivalent in part-time service at an eligible Employer Healthcare Organization according to the specifications in the MLRP Program Guide. By signing this application, I agree to all of the conditions stipulated in the MLRP Program Guide. Applicant (Health Professional) Signature Date (First) Print Name Middle Initial (Last) 2 of 2 Health Professional Information Form

4 Employer Information Form Employer Healthcare Organization: Employer Address: Street City Zip Code Employer Contact Name: Title: Employer Phone #: Medicaid Billing #: Employer Contact Healthcare Organization Employer Qualifications* Type of Shortage Designation: HPSA # / MUA #: HPSA Score: * Shortage designation information can be found at: Name of Applicant/ Health Professional: (First) (Middle Initial) (Last) # hours /week of direct out-patient care: # hours /week of non-patient care duties: Describe the need for this health professional at your organization and the type of patients/population he/she will care for (eg. homeless, LGBT): If the site is supporting more than one health professional application for this year, please indicate the priority preference of this application relevant to other applications submitted by the site for this year. Circle one: of 3 Employer Information Form

5 Employer Information Form Provide assurance of employer eligibility criteria by initialing the following items as appropriate: Statement Health professional applicant will provide services in a public or a non-profit organization that holds any necessary MDPH licenses. The employer healthcare organization (and billing entity if different) is certified as a provider by MassHealth and complies with the regulations governing MassHealth; accepts Medicare; and accepts patients enrolled in Commonwealth Care programs. The employer healthcare organization (and billing entity if different) is certified as a provider by MassHealth and has a rate established by the Division of Health Care Finance and Policy; and is in compliance (good standing) with MassHealth regulations and certifications. Applicant employer healthcare organization (and billing entity if different) must charge for their professional services at the usual and customary prevailing rates in the area in which such services are provided, except if a person is unable to pay the charge, such person shall be charged at a reduced rate using a schedule of fees for those at various income levels and will display a notice of availability of discounted fees for the uninsured (i.e. sliding fee scale) or not charged any fee. The employer healthcare organization must provide documentation of fee schedule or sliding fee scale and policy. The employer health care organization agrees to provide primary care services as provided by the eligible health professionals and defined in the Program Guide, to any individual seeking care. MLRP awardees and employer (and site, if different) must agree not to discriminate on the basis of the patient s ability to pay for such care or on the basis that payment for such care will be made pursuant to Medicaid/MassHealth, Medicare, the State Children s Health Insurance Program and/or the Commonwealth Care Programs and/or through the sliding fee scale. A support letter from the employment site if different than the hiring employer organization (see the section Obligations of the Employer Healthcare Organization in the Program Guide) is attached, if appropriate. Affirmation (Initials) The applicant Employer Healthcare Organization certifies that it meets the eligibility requirements and has provided truthful information regarding the employment of the applicant and understands the need for compliance with all specifications set forth by the Massachusetts Loan Repayment Program (MLRP) for Health Professionals Program Guide. The Employer Healthcare Organization certifies that loan repayment funds will not be used to supplant an MLRP provider's expected wages or benefits as compared to other similarly qualified and situated employees. As a representative of I recommend this applicant for the MLRP. (Employer Healthcare Organization) SIGNATURE OF AUTHORIZED REPRESENTATIVE: Signature Date (First) (Middle initial) (Last) Print Name & Title 2 of 3 Employer Information Form

6 Employer Information Form Payor Mix Information Provide the following patient payor mix percentage. This payor mix information should come from agency billing or financial data. Note: refer to health insurance options for low income residents at Medicaid (MassHealth) only Medicaid /Medicare Dual Eligible Commonwealth Care Health Safety Net (Free Care) Commonwealth Choice Children s Medical Security Medicare only Self Pay Other Uninsured % of Patient Population Please state from where the above data was derived, and the time period it represents. Signature of Authorized Representative: Signature First Middle initial Last Print Name Print Title 3 of 3 Employer Information Form

7 Health Professional's Qualifying Loan Statement Please attach a copy of your: 1) Student loan statement (must be current and complete) 2) Pay Stub Loan statement should be from the month previous to, or month of, this application. Must include relevant full Name and Address HIGHLIGHT each outstanding loan on the loan statements. Below please list each student loan dollar amount Include a copy of a pay stub from your practice site from month previous to, or month of, this application. Total loan amount$ What is your current total annual salary? What is the amount you are requesting from the MLRP? $ $ Amount awarded by the MLRP will not exceed total outstanding loan amount. Health Professionals Qualifying Loan Statement

8 Standard Contract Form Name of Applicant (Health Professional/Contractor): Home Address: Street City State Zip Name of Applicant s Practice Site: Practice Site Address: Street City State Zip CERTIFICATIONS: The Effective Date of this Contract shall be the latest date this Contract was signed by an authorized signatory of the Massachusetts Department of Public Health. By executing this Contract, the Contractor makes, under the pains and penalties of perjury, all certifications required under the terms of the Program Guide. Additionally, the Contractor certifies he/she has not been in bankruptcy and/or receivership within the last three calendar years, and certifies that he/she will immediately notify the Department in writing if there is any risk to the solvency of the Contractor that may impact the Contractor s ability to timely fulfill the terms of this Contract. The Contractor shall affirmatively disclose the details of any pertinent judgment, criminal conviction, investigation or litigation pending against the Contractor. The Contractor agrees to all terms governing performance of this Contract, as stated in the Program Guide, the Commonwealth Terms and Conditions, and any additional negotiated performance or budget provisions. The terms of this Contract shall survive its termination for the purpose of resolving any claim, dispute or other Contract action, or for effectuating any negotiated representations and warranties. By executing this Contract, the Contractor under the pains and penalties of perjury, makes all certifications required under the certifications listed below, and has provided all required documentation, or shall provide any required documentation upon request, and the Contractor agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached to this Contract or incorporated by reference herein the Program Guide, the Contractor s response to the Program Guide, and any additional non-conflicting negotiated provisions: The Contractor is qualified and shall at all times remain qualified to perform this Contract; that performance shall be timely and meet or exceed industry standards, including obtaining requisite licenses, registrations, permits and resources for performance. The Contractor shall comply with the terms of the Program Guide, and any additional negotiated provisions for this Contract. Health Professional/Contractor SIGNATURE: X: Date: (Signature and Date Must Be Handwritten At Time of Signature) Print Name: Print Title: MDPH Representative Signature: X: Date: Print Name: Julia Dyck Print Title: Director, HCWC MDPH Use Only: HPSA# CONTRACT START DATE: CONTRACT END DATE: Vendor Code: Department MMARS Alpha Code and Name: MDPH Business Mailing Address: 250 Washington St, 5 th Fl., Boston, MA Contract Manager: Nicole Watson Address: [email protected] Phone: Fax: MMARS Doc ID(s): Program Guide/Procurement or Other ID Number (if applicable): Account(s) Funding Contract TTY: Award Amount: $ Standard Contract Form

9 W-9 Form Please click on link below to download and complete this form Please include the completed W-9 form in your application. Electronic Funds Transfer Form Please click on link to download and complete this form: Include a voided check with your application. W-9 Form/ Electronic Funds Transfer Form

10 Essay Choose one of the two essays. Essay should be typed words. Please complete essay on a separate sheet of paper and attach to the application package. Include in the header your name, the name of the practice site, the date of your application, and the question you are answering. 1. Describe your education, practice, and other relevant experiences which you believe qualify you to work in an underserved community or with underserved populations. Please give concrete examples of what has prepared you to work with the population served by your current site. 2. Describe your patient population including health disparities experienced by that population. Describe how you as a health care provider have been or will address these disparities and /or improve the health outcomes of the patient population (e.g. community outreach / education, support groups, research). Essay