DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Public Health

Statutory Authority: 16 Delaware Code, Section 122 (16 Del.C. 122)

FINAL

SUMMARY OF AMENDMENTS TO EXISTING REGULATIONS

STATE OF DELAWARE RULES AND REGULATIONS PERTAINING TO THE:

DELAWARE CONRAD STATE 20 / J-1 VISA WAIVER PROGRAM

These are nonsubstantive changes, which are to be informally adopted in accordance with Delaware Code, Title 29, Chapter 101, Section 10113 to ensure that the Delaware Regulations for the Conrad State 20/J-1 Visa Waiver Program remain consistent with changes made at the Federal level. The changes reflect the new Federal requirements to include two self-addressed stamped envelopes and the addresses (one post office box and one physical) to which the application fee and physician data sheet should be sent.

Questions regarding the nonsubstantive changes should be directed to Katherine Collison at the following:

Health Systems Development Branch

Jesse Cooper Building, P.O. Box 637

Dover, DE 19903

Telephone: (302) 739-4735

Conrad State 20/J-1 Visa Waiver Program

APPLICATION REGULATIONS

JULY 1999

Conrad State 20/J-1 Visa Waiver Program

Policy and Procedures

I. PURPOSE

This document will specify the procedures to be used by the Delaware Health and Social Services (DHSS) in administering the Conrad State 20/J-1 Visa Waiver Program (Program).

II. AUTHORITY

Delaware Code, Title 16, Chapter 1, Section 122, Public Law 103-416 United States Code

III. BACKGROUND

International medical graduates (IMG) completing their graduate medical education in the United States under a J-1 Visa are required to return to their country of nationality for at least two years before reentering the United States. Acting as an interested state agency, DHSS may make a recommendation to the U.S. Department of State, Bureau of Consular Affairs Waiver Review Division (DOS) to, in turn, recommend that the Immigration and Naturalization Service (INS) waive the home residence requirement for up to twenty (20) J-1 physicians annually. Additionally, a J-1 physician may apply directly to the United States Department of Agriculture (USDA) for a J-1 visa waiver. In order to receive a letter of support for the J-1 physician applicant from DHSS, however, applications must first meet Program requirements, described herein.

IV. POLICY STATEMENTS

DHSS is committed to ensuring that quality health care is available to all residents of the State of Delaware. In an effort to ensure adequate medical services are provided in underserved areas, DHSS has elected to take advantage of the Conrad State 20/J-1 Visa Waiver Program.

Under this program, DHSS has established state-specific procedures that require sponsoring sites to submit a Site Application. This application consists of 1) a needs assessment, 2) proof that the sponsoring site has unsuccessfully attempted over a six month period to hire a physician with United States citizenship, 3) three letters of support from community leaders and local public health officials, 4) strategy for long-term and short-term retention, 5) sponsoring site waiver agreement, and 6) a site application form.

The needs assessment must establish and document that a particular need exists within the sponsoring site’s service area before the site will be approved to hire a J-1 physician under the Conrad State 20/J-1 Visa Waiver Program. The onus to establish the need rests solely with the sponsoring site.

The Site Application will be reviewed and approved or disapproved by a Board. DHSS will provide written notice to the site of the application’s approval/disapproval. A J-1 visa waiver application on behalf of a particular J-1 physician may not be submitted until the sponsoring site has been approved. J-1 visa waiver applications will only be accepted from J-1 physicians who have signed a contract with a pre-approved site.

DHSS will submit recommendations to the DOS on behalf of qualified J-1 physician applicants who agree to practice medicine full-time at a pre-approved sponsoring site for a minimum of three years in a federally designated Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA) of Delaware with a pre-approved site.

DHSS participation in the Conrad State 20/J-1 Visa Waiver Program is completely discretionary and voluntary. DHSS may elect not to participate in the Program at any time. The submission of a complete waiver package does not ensure DHSS will recommend a waiver in all instances. No more than 20 applications will be approved each Federal fiscal year. DHSS reserves the right to recommend or decline any request for a waiver.

This policy applies in full to any waiver submitted on behalf of a J-1 physician to be employed in Delaware.

V. DHSS DUTIES AND RESPONSIBILITIES

The Health Systems Development Branch of the Delaware Division of Public Health (DPH) has primary responsibility within DHSS for processing J-1 visa waivers. DHSS serves as the “interested state agency” with the Director of Public Health having the authority to sign the recommendations. Applications must be processed in the best interest of the health care needs of Delawareans.

VI. APPLICABILITY

These procedures apply to the following:

• All J-1 physicians seeking a J-1 visa waiver under PL 103-416 for employment in Delaware.

• All sponsoring sites seeking approval to hire a J-1 physician under the J-1 Visa Waiver program.

• All DHSS employees processing J-1 visa waivers under PL 103-416.

VII. APPLICATION PROCESS

Sponsoring Site Pre-Approval Application Requirements

The Site Application (see Appendix A for Application forms) must, at a minimum, include the following:

A. Site Application Form:

1. Sponsoring Site: Provide the name, address, county, telephone number, fax number and the e-mail address of site requesting approval to hire a J-1 physician. Also, please specify if the site is for profit or not for profit.

2. Practice Site: Provide the name, address and county of actual practice site where the requested J-1 physician would practice, if different from the primary location of the sponsoring site.

3. Recruitment Contact: Provide the name, address, county, telephone number, fax number and e-mail address of the individual responsible for physician recruitment.

4. Site Data Regarding Active Clients: Provide the total number of active patients at the practice site in the previous calendar year. Indicate total patients, as applicable, for primary care, specialty care and mental health services. Provide pro-rated or estimated annual totals if the site was not operational for the entire previous calendar year. For new sites, estimate the number of patients anticipated for the next year. Of the total number of patients, provide the percentage of all current patients, broken out by given age groups, making payment by conventional insurance plans, Medicare, Medicaid or on a sliding fee scale. A copy of the sliding fee scale must be submitted.

5. Staffing Levels: Provide the total number of budgeted full-time equivalent providers currently on staff. Also include the number of J-1 physicians requested, by specialty, and the projected hire date of each.

6. Practice Site Hours of Operation: Indicate the normal operating hours of the practice site by the days of the week. If hours of operation vary by practitioner, please specify.

7. Proposed J-1 Physician Weekly Work Schedule: Indicate the proposed weekly work schedule of the proposed J-1 physician(s). Include the number of hours (with start and end times) and the location (hospital/practice site(s)). The schedule must indicate the amount of time the J-1 physician is actually providing services; do not include travel or on-call time.

B. Needs Assessment:

Sponsoring sites are encouraged to work with their local hospital to complete the needs assessment. A comprehensive, data driven needs assessment must be completed, which, at a minimum, includes the following:

1. Description of the service area in which the sponsoring site’s patients are located.

2. Geographic Service Area Health Resource Inventory. Description of the other health care resources located within the same service area including physicians (by specialty), hospitals, clinics, urgent care centers and any other available outpatient care facilities. Also include the location of the nearest available source of outpatient based services, which offers a sliding fee scale to patients with limited financial resources and that provides services similar to those that are being provided by the requested J-1 physician. Using public transportation as the mode of travel, indicate the distance and travel time to that site.

3. Documentation that the sponsoring site’s service area is located within a Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA). Please indicate the following: HPSA Type(s), HPSA Service Area Number, HPSA FIPS State/County Code and the sponsoring site’s primary service area (by City/County).

4. Documentation of a shortage in the defined service area for the particular physician specialty being requested under the J-1 Visa Waiver Program.

• Provide statistics demonstrating the need for a specialty and/or sub-specialty in the sponsoring site’s service area.

• Document that the specialty and/or sub-specialty is not available to the underserved population in the service area.

• Describe how a J-1 physician would be used to meet the needs of the underserved population in the service area. Indicate if unique qualifications, such as cultural match or experience with the service area’s underserved population, are sought to meet a particular need.

C. Retention:

The sponsoring site must provide written documentation of plans to retain the J-1 physician in the service area upon completion of the three-year practice obligation. Specifically, this plan must include short and long-term strategies that will not only keep the physician in the service area, but also will encourage the physician to continue to practice the specialty for which he/she was hired.

D. Proof of Failed Recruitment Attempts:

The sponsoring site must provide proof that attempts have been made to hire a physician with United States citizenship in the past six months to no avail. This section must include a written description of the failed attempts to recruit as well as back up documentation including, but not limited to, medical journal and newspaper advertisements, letters to medical residency programs and/or medical schools, etc. Please state any attempts to gain recruitment support from the hospital within the practice site’s geographic service area.

E. Letters of Support:

The sponsoring site must submit three letters of support. Two must be obtained from community members and/or leaders in the practice site’s service area. One must be obtained from a local public health official (see Appendix B for an approved contact list). Each letter must indicate the benefits of, or need for, the placement of a J-1 physician with the sponsoring site.

F. Sponsoring Site Waiver Agreement:

The director or applicant official of the sponsoring site must initial each of the statements indicating agreement to comply with requirements of the Delaware Conrad State 20/J-1 Visa Waiver Program. The form must also be signed and dated to include the title of the applicant official.

G. Signature:

The director or applicant official of the sponsoring site must provide an original, dated application with a live signature (using blue ink). This signature binds the site to the information provided and verifies that the form has been completed with accurate and current information.

J-1 Physician Application Requirements

Applications will only be accepted from J-1 physician applicants who already have an employment contract with a pre-approved sponsoring site (see section IV above). The completed application must include the original application package and one complete copy. No more than 20 applications will be approved each Federal fiscal year. DHSS reserves the right to recommend or decline any request for a waiver.

The J-1 Physician Application (see Appendix C for application forms) must, at a minimum, include the following:

A. Letter from the Director of the Sponsoring Site:

The director of a pre-approved sponsoring site must submit a letter requesting a DHSS recommendation to the DOS (or other Federal approving agency) that a J-1 physician be given a waiver of the requirement to return to their country of nationality. The letter must include, or attach, each of the following:

• Description of the J-1 physician's qualifications, proposed responsibilities and how his/her employment will meet currently unmet health care needs of a medically underserved community.

• If the J-1 physician will be practicing in a HPSA or MUA that is based on a population group, the employer must provide adequate documentation of the medical care that will be provided to this group.

• Certification that the J-1 physician will provide medical care services to Medicare, Medicaid and medically underserved patients, without discrimination based upon ability to pay for such services (i.e. self-pay, sliding fee scale, charity care).

• Completed Physician Data Sheet (copy enclosed).

• Copy of the J-1 physician’s curriculum vitae (CV).

• Evidence of eligibility for a Delaware medical license.

• At least three letters of recommendation from persons familiar with the J-1 physician’s work.

• A signed statement from the J-1 physician agreeing to the contractual requirements set forth in Section 214 (k)(1) (B) and (C) of the Immigration and Nationality Act.

• Copies of all IAP-66 forms issued to the J-1 physician seeking the waiver.

B. Employment Contract:

The employment contract must, at a minimum, include the following:

• Name and address of the sponsoring site.

• Name and address of the location of the sponsoring site’s practice. If the J-1 physician will work at more than one site, include the days and hours of practice at each site and a breakdown in the amount of time the physician will practice at each site.

• A statement that the J-1 physician will work not less than four days per week or more than 12 hours in a 24 hour period. The hours must be performed during normal office hours, or hours which best meet the needs of the community (e.g. evenings and/or weekends). Travel and on-call time can not be included.

• A statement that the site will employ the physician on a full-time basis (minimum of 40 hours per week, not including time spent in travel and/or on-call).

• Statement that the J-1 physician will commence practice within 90 days of receiving a waiver and will practice on a full-time basis for at least three years.

C. Letter of No Objection from Home Country:

A statement that the physician's home country has no objection to the physician receiving a waiver of the foreign residence requirement must be included if the J-1 physician received funding from his or her home country for medical education or training in the United States. The Certification Regarding Contractual Obligation to Home County (HD1061F) letter must be submitted directly to the following address by the J-1 physician applicant:

Waiver Review Division

Department of State

Bureau of Consular Affairs, Visa Office

CA/VO/L/W Room, L603

2401 E Street, NW

Washington, DC 20522-0106

D. Evidence of Payment of the Department of State ‘User Fee Required for Waiver Processing’:

The J-1 physician applicant must provide proof that the $136.00 processing fee has been sent to the DOS. A copy of the payment (i.e. check or money order) is considered sufficient proof. DHSS will not handle the submission of this fee. The fee must be mailed directly to the following address at the time the J-1 Visa Waiver Application packet is submitted to DHSS:

Waiver Review Division

Department of State

Bureau of Consular Affairs, Visa Office

CA/VO/L/W Room, L603

2401 E Street, NW

Washington, DC 20522-0106

Submission of Payment of the Department of State ‘User Fee Required for Waiver Processing’:

The J-1 physician applicant must provide proof that the $136.00 processing fee has been sent to the DOS. A copy of the payment (i.e. check or money order) is considered sufficient proof. DHSS will not handle the submission of this fee. The fee must be mailed directly to the DOS at the time the J-1 Visa Waiver Application packet is submitted to DHSS. The submission of the fee must adhere to the following requirements:

• A copy of the Physician Data Sheet and two self-addressed, stamped, legal-size envelopes must accompany the $136.00 DOS user fee. The applicant’s full name, date of birth and social security number must be included on the check or money order, which must be drawn on a bank or other institution located in the United States and made payable to the United States DOS in U.S. currency. If the applicant resides outside the U.S. at the time of application, remittance may be made by bank international money order of foreign draft drawn on an institution in the U.S. and made payable to the United States DOS in U.S. currency. The envelopes will be used to inform the applicant of 1) the case number, which must be included on all future correspondence with DOS, and 2) the approval determination.

• The address to which you must submit these items follows, depending on whether the United States Postal Service or a Courier Service is selected:

If Sending Via United States Postal Service:

US Department of State

Waiver Review Division

Post Office Box 952137

St. Louis, MO 63195-2137

If Sending Via Courier Service:

US Department of State

Waiver Review Division (Box 952137)

1005 Convention Plaza

St. Louis, MO 63101-1200

E. J-1 Visa Waiver Statements:

The J-1 physician applicant must sign and include the enclosed ‘J-1 Physician Waiver Statements.’

F. J-1 Visa Waiver Affidavit and Agreement:

The J-1 physician applicant must include a notarized ‘J-1 Visa Waiver Affidavit and Agreement.’ The document must contain the J-1 physician applicant’s live, notarized signature (in blue ink).

G. J-1 Visa Waiver Application Checklist:

The enclosed checklist must accompany the application. The J-1 physician applicant must initial each item on the checklist as proof and assurance that each item is included in the waiver application packet.

VIII. SITE APPLICATION EVALUATION PROCESS

The Delaware Conrad State 20/J-1 Visa Waiver Program Sponsoring Site Application Review Board (Board) will review and approve or disapprove each Site Application based on its individual merits. Board members must not serve on the review panel for applications submitted by sponsoring sites with which they have either a personal or employment-related conflict of interest. The Board will be comprised of, at least, one member from each hospital in the state, the Medical Society of Delaware, the Health Care Commission and DHSS representatives.

A. Sponsoring Site Application Preliminary Review:

A preliminary review of each application will be conducted by the Conrad State 20 Program manager to determine if 1) the sponsoring site is located within a HPSA/MUA and 2) that the following required documentation is completed:

• Sponsoring Site Application

• Detailed Needs Assessment

• Strategy for Long-term and Short-term Retention

• Proof of Failed Recruitment Attempts

• Letters of Support

• Sponsoring Site Waiver Agreement

The preliminary review will be conducted solely for the purpose of determining the completeness of the application; the specific content provided in each of the components will not be considered. Incomplete applications, as well as applications from a site not located in a HPSA/MUA, will be returned to the sponsoring site immediately. A checklist identifying the missing information will be included. Completed applications may be resubmitted at any time prior to the first Monday in December.

B. Sponsoring Site Application Review:

The Board will convene during the month of January to review the applications submitted by the first Monday of December.

Using the Site Application Evaluation (see Appendix D for the form) as a guide, Board members must assign a score to each of the elements on the Site Application Evaluation form.

The following point scale has been assigned to each unique element:

Review Point Scale

Site Application Data 25

Needs Assessment 35

Retention 15

Proof of Failed Recruitment Attempts 15

Letters of Support 10

Total 100

The scores from the review element will be averaged to reach an overall total score for each Board member. The total scores received from each Board member will then be averaged to determine the final score for each site.

Sites will be approved only if:

1) all criteria is met,

2) a final score not lower than a 70 is achieved, and

3) an overall score of at least a twenty-five (25) is achieved on the Needs Assessment component.

Approved sponsoring sites (whose applications were received by the first Monday in December) will be eligible to make a contractual offer to a J-1 physician for the following fiscal year (beginning October 1^st of each year). However, if not all twenty Conrad State 20/J-1 Visa Waiver slots have been used for the current Federal fiscal year, approved sponsoring sites may make a contractual offer to a J-1 physician for the current fiscal year and the physician may submit a J-1 visa waiver application packet (see Appendix C for forms) immediately.

C. Review of Applications Submitted After the First Monday in December:

Applications received after the December deadline will be reviewed to determine if an emergent need (see Glossary for examples) for the placement of a J-1 physician is demonstrated. The application must include a detailed explanation as to the reason(s) the application was not submitted by the first Monday in December. If not all twenty Conrad State 20/J-1 Visa Waiver slots have been used for the current fiscal year, sponsoring sites demonstrating an emergent need may make a contractual offer to a J-1 physician immediately upon approval and the physician may submit a J-1 visa waiver application packet (see Appendix C for forms) for the current fiscal year. If all twenty Conrad State 20/J-1 Visa Waiver slots have been used, then approved sponsoring sites must wait until the following Federal fiscal year (beginning October 1^st of each year) to submit a J-1 physician waiver application or may submit via the USDA.

D. Notice of Approval/Disapproval:

For those applications received by the first Monday in December, DHSS will provide written notification of the Site Application’s approval or disapproval by February 15^th of each year.

Applications submitted after the first Monday in December will receive written notification of the Site Application’s approval or disapproval within 45 days from the date of receipt of the application by DHSS.

IX. TIME FRAMES

Site Application Submission DHSS will accept Site Applications Forms each year through the end of the business day on the first Monday in December. Site Applications submitted after the first Monday in December will be eligible to receive approval only if 1) DHSS has not used the allotted twenty recommendations for the year, and 2) an emergent need for the placement of a J-1 physician is clearly demonstrated.

Site Notification DHSS will notify sponsoring sites in writing of the decision to approve or disapprove their site no later than February 15^th of each year. Inquiries regarding the status of pending applications will not be accepted at any time prior to February 15^th.

J-1 Visa Waiver Request Submission J-1 Visa Waiver Requests may be submitted with the start of each Federal fiscal year, October 1^st.

X. COMPLETED SITE APPLICATIONS AND ASSOCIATED J-1 APPLICATIONS MUST BE SENT TO:

Conrad State 20 Program Manager

Division of Public Health

Health Systems Development Branch

P.O. Box 637

Dover, Delaware 19903

XI. SUBMITTING J-1 PHYSICIAN WAIVER RECOMMENDATION TO DOS

If the J-1 visa waiver request is approved, a cover letter to DOS is prepared by DHSS identifying the J-1 physician applicant and recommending a waiver of the two-year home residence requirement be granted. Upon receipt of the DHSS approval request, DOS will review the application.

XII. J-1 PHYSICIAN APPLICANTS RECEIVING A J-1 WAIVER

J-1 physician applicants receiving approval of a J-1 Waiver request must begin work at the sponsoring site within ninety (90) days of notice of approval from DOS.

XIII. REPORTING REQUIREMENTS

An annual reporting process is utilized for each J-1 physician practicing under a waiver to ensure the J-1 physician continues to practice in an underserved area of Delaware for the required three years. DHSS will forward an Annual Practice Form (see Appendix E for a sample form) to the sponsoring site within thirty (30) days of the anniversary of the J-1 physician’s start date. The sponsoring site must forward the signed, completed Annual Reporting Form to DHSS. An annual reporting form must be submitted for each year of practice obligation.

Notification of waiver status and commencement of employment contract must be submitted to DHSS upon receipt of written notification of approval from INS. This notification must include the date the three-year obligation commences.

Contract changes which result in termination of contract, change in practice scope, and/or relocation from a site approved in the application request to a new site must be presented in writing to DHSS at least thirty (30) days prior to the change. All reporting requirements, changes in practice location and/or scope must be submitted to the following:

Conrad State 20 Program Manager

Division of Public Health

Health Systems Development Branch

P.O. Box 637

Dover, Delaware 19903

XIV. EXIT INTERVIEW

Each J-1 physician practicing in Delaware must complete an exit interview within ninety (90) days of completion of his/her three-year obligation, or at such point that the employment contract is terminated by either the sponsoring site or the J-1 physician. DHSS will conduct the exit interview, which will concentrate on the J-1 physician’s experiences in Delaware and their future plans for practicing medicine at the current, or another location.

XV. J1 VISA WAIVER APPLICATION GLOSSARY

Department of State, Bureau of Consular Affairs Waiver Review Division (DOS) The Federal agency that reviews the recommendations submitted by interested state agencies on behalf of J-1 physician applicants. In turn, they submit their own recommendation to the Immigration and Naturalization Service for final determination of approval/disapproval.

Emergent Need An emergent need is one that demonstrates a critical need for the placement of a J-1 physician. An emergent need includes, but is not limited to, the following: departure, death or retirement of a clinical physician providing a majority of medical care needs.

Health Professional Shortage Area (HPSA) An area defined by the Department of Health and Human Services as having a shortage of health care providers.

J-1 Physician An international medical graduate physician completing graduate medical education in the United States under a J-1 Visa. These physicians are required to return to their country of nationality for at least two years before reentering the United States unless a J-1 Visa waiver is granted.

Medically Underserved Area An area, as defined by the Department of Health and Human Services, as not having an adequate supply of health care providers.

Practice Site Actual physical location at which the J-1 physician will provide medical services. This location can be different from the sponsoring site location if, for example, a satellite office is used.

Primary Care Fields The following four fields are identified as primary care: family practice, general internal medicine, general pediatrics and obstetrics/gynecology

Recruitment Contact Primary point of contact to be used by Delaware Health and Social Services Conrad State 20 Program Manager.

Service Area Geographic area in closest proximity to the practice site, from which the majority of patients are derived.

Sponsoring Site Medical practice through which the J-1 physician will provide medical services (i.e. the hiring organization).

APPENDIX A

CONRAD STATE 20/J-1 VISA WAIVER SITE

APPLICATION FORMS

I. SITE APPLICATION FORM

1. Sponsoring Site: ___________________________

Street Address: ____________________________

City: _______ State: ____ Zip: _____ County: __

Telephone Number: _____ Fax Number: ______

E-Mail Address: ___________________________

Non-Profit: __________ For Profit: __________

2. Practice Site: _____________________________

Street Address: ____________________________

City: _______ State: ____ Zip: _____ County: __

3. Recruitment Contact: _______________________

Street Address: ____________________________

City: _______ State: ____ Zip: _____ County: __

Telephone Number: _____ Fax Number: ______

E-Mail Address: ___________________________

4. Site Data Regarding Active Clients:

Total Number of Patients Receiving the Following Medical Services:

Primary Health Care: ____ Specialty Care: ____ Mental Health Care: _____ Total: _____

Total Users in Previous Calendar Year Below 200% of Federal Poverty Level: ______

5. Staffing Levels

AREA OF PRACTICE

STAFFING LEVEL

NUMBER OF J-1 PHYSICIANS REQUESTED

PROJECTED HIRE DATE

FULL

CURRENT

JUNE – AUG 2000

SEPT – NOV 2000

DEC – FEB 2000

MARCH –MAY 2000

PRIMARY CARE PHYSICIANS

Family Practice

General Internal Medicine

General Pediatrics

Obstetrics/Gynecology

SPECIALIST PHYSICIANS (Please Specify Specialty Area)

NURSE PRACTITIONERS

Family Nurse Practitioners

Adult Nurse Practitioners

Geriatric Nurse Practitioners

Pediatric Nurse Practitioners

Women’s Health Nurse Practitioners

Psychiatric Nurse Practitioners

OTHER DISCIPLINES

Physician Assistants

Nurse Midwives

Clinical Psychologists

Clinical Social Workers

Psychiatric Nurse Specialist

Marriage and Family Therapists

. Practice Site Hours of Operation.

If hours of operation vary by practitioner, please specify.

7. Proposed J-1 Physician Weekly Work Schedule:

Provide a separate work schedule for each J-1 physician requested and specify the specialty of each.

II. NEEDS ASSESSMENT

Please use additional paper to complete this section.

1. Description of the service area in which the

sponsoring site’s patients are located:

2. Geographic Service Are Health Care Resource Inventory

Practice Site	Specialty	Hospital Hours? Y/N	Total Office Hours Per Week	Accept Medicaid? Y/N	% Medicaid	Accept New Patients? Y/N	Sliding Scale? Y/N	% Charity Care

lude all medical services available in the service area for which the J-1 physician will be practicing.

NEAREST AVAILABLE SITE PROVIDING SERVICES SIMILAR TO PROPOSED J-1 PRACTICE SITE (INCLUDE COMPLETE NAME AND ADDRESS)	MILES TO NEAREST SITE	TRAVEL TIME TO NEAREST SITE (using public transportation)

3. Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA) Documentation.

HPSA Y/N Location: ___________________________

MUA Y/N: Location: ___________________________

Sponsoring Site’s Primary Service Area

(City, County, Zip Code & Census Tract) ___________

4. Documentation of a shortage in the defined servcie area for the particular physician specialty being requested under the J-1 Visa Waiver Program.

a) Provide statistics demonstrating the specialty/sub-specialty is greatly needed in the sponsoring site’s service area.

b) Document that the specialty/sub-specialty is not currently available to sufficiently meet the need in the service area for the underserved population.

c) Describe how a J-1 physician will be used to meet the underserved population needs in the service area; indicate if unique qualifications, such as language/cultural match or experience with a poplulation similar to those in the service area, are sought to meet a particular need.

III. RETENTION

Describe the short and long-range plan for the retention of a J-1 physician beyond the required three-year obligation. Please use additional paper.

IV. PROOF OF FAILED RECRUITMENT ATTEMPTS

DATE	METHOD OF RECRUITMENT	RESPONSE	REASON FOR DISCONTINUING METHOD

V. LETTERS OF SUPPORT

Attach original, signed letters from two separate community members and/or leaders in the practicing site’s service area. Attach one original, signed letter from an approved local Public Health official (see Appendix B for an approved contact list).

VI. SPONSORING SITE WAIVER AGREEMENT

Delaware Health and Social Services (DHSS) is committed to ensuring that all residents have access to quality, affordable health care. Accordingly, DHSS is prepared to consider recommending a waiver of the foreign residence requirement on behalf of physicians holding J-1 Visas under certain conditions. Therefore, the additional requirements are deemed necessary to support our Conrad State 20/J-1 Visa Waiver Program.

The director or applicant official for the facility or practice must initial all of the following requirements:

_____ Sponsoring site agrees to comply with all of the Program requirements set forth in this Agreement and guidelines.

_____ The sponsoring site is located in a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA), as designated by the Secretary of Delaware Health and Human Services.

_____ The J-1 physician will provide medical care for at least forty (40) hours a week at the HPSA or MUA site named in the application for a minimum of three (3) years. Travel or on-call time is not included in the required forty (40) hours.

_____ The sponsoring site agrees to provide health services to individuals without discriminating against them because (a) they are unable to pay for those services, or (b) payment for those health services will be made under Medicaid and Medicare. The sponsoring site will charge persons receiving services at the usual and customary rate prevailing in the HPSA/MUA in which services are provided, except charges will be on a sliding scale for persons at or below 200 percent of poverty or at no charge for persons unable to pay for these services.

_____ The sponsoring site has made a reasonable, good faith effort to recruit a physician with United States citizenship for the job opportunity in the same salary range without success during the last 6 months immediately preceding this request for a waiver. Recruitment efforts were through a number of appropriate sources most likely to bring responses from able, willing, qualified and available physicians with United States citizenship.

_____ I understand and acknowledge that the review of this site application is discretionary and that in the event a decision is made not to approve the site application, I hold harmless the State of Delaware, DHSS and any and all State employees and/or any and all individuals or organizations involved in the review process from any action or lack of action made in connection with this request.

VII. SIGNATURE

Signature of Applicant Official: ______________________

Title: ___________________________ Date: ____________

APPENDIX B

CONRAD STATE 20/J-1 VISA WAIVER

J-1 PHYSICIAN APPLICATION LETTER OF SUPPORT CONTACT LIST

The following are approved public health officials to contact to obtain a letter of support to include with the J-1 Visa Waiver Site Application. If the practice site is located in New Castle County, please contact Shirlee Kittleman. If the practice site is located in Kent or Sussex Counties, please contact Barbara DeBastiani.

Northern Health Services Southern Health Services

Shirlee Kittleman, Barbara DeBastiani,

Administrator Administrator

2055 Limestone Road, Sussex County Health Unit

Suite 300 544 South Bedford Street

Wilmington, DE 19808 Georgetown, DE 19947

Phone: (302)995-8632 Phone: (302)856-5355

Fax: (302)995-8616 Fax: (302)856-5065

APPENDIX C

CONRAD STATE 20/J-1 VISA WAIVER

J-1 PHYSICIAN APPLICATION FORMS

J-1 VISA WAIVER REQUEST

DOS PHYSICIAN DATA SHEET

1. FULL NAME: ________________________________

2. DATE OF BIRTH: ________ PLACE OF BIRTH: ____

3. COUNTRY OF NATIONALITY OR LAST LEGAL

PERMANENT RESIDENCE: ____________________

4. DATE AND PLACE OF ISSUANCE OF ORIGINAL

EXCHANGE-VISITOR (J-1) VISA: _______________

5. PRESENT HOME ADDRESS: ___________________

____________________________________________

IMMIGRATION DISTRICT: ___________________

6. HOME TELEPHONE: _________________________

BUSINESS TELEPHONE: _____________________

7. LIST OF EXCHANGE-VISITOR PROGRAMS IN

WHICH YOU PARTICIPATED. IF KNOWN, GIVE

THE PROGRAM NUMBER AND THE FIELD OF

SPECIALIZATION: ___________________________

____________________________________________

8. ALIEN REGISTRATION NUMBER, IF KNOWN:___

9. IF YOUR EXCHANGE-VISITOR PROGRAM

INCLUDES US GOVERNMENT FUNDS, FUNDS

FROM YOUR OWN GOVERNMENT, OR FROM AN

INTERNATIONAL ORGANIZATION. PLEASE

GIVE FULL PARTICULARS CONCERNING THE

FUNDING ON A SEPARATE SHEET.

10. IS YOUR SPOUSE IN J-1 STATUS? YES ___ NO___

IF SO, IS HE/SHE ALSO APPLYING FOR A

WAIVER? (PLEASE GIVE A FULL EXPLANATION

ON A SEPARATE SHEET)

11. GIVE THE REASONS FOR NOT WISHING TO

FULFILL THE TWO YEAR HOME COUNTRY

RESIDENCE REQUIREMENT TO WHICH YOU

AGREED AT THE TIME YOU ACCEPTED

EXCHANGE VISITOR STATUS. PLEASE GIVE A

FULL EXPLANATION ON A SEPARATE SHEET.

12. PLEASE INCLUDE COPIES OF ALL IAP-66 FORMS

ISSUED DURING YOUR STAY IN THIS

COUNTRY.

______________________________________ _______

SIGNATURE OF J-1 PHYSICIAN APPLICANT DATE

J-1 PHYSICIAN WAIVER STATEMENTS

DECLARATION OF PENDING INTERESTED GOVERNMENT AGENCY

I, _________________________, hereby declare and certify, under penalty of the provisions of 18 U.S.C. 1101, that I do not now have pending nor am I submitting during the pendency of this request, another request to any United States Government agency or any State Department of Public Health, or equivalent, other than the Delaware Health and Social Services to act on my behalf in any matter relating to a waiver of my two-year-home-country physical presence requirement.

________________________________ ______________

Physician Signature Date

________________________________

Physician Name (Printed or Typed)

MEDICAL LICENSE AFFIDAVIT

I, _______________________, hereby affirm that, to the best of my knowledge, my medical license has never been suspended or revoked and that I am not subject to any criminal investigation or proceedings by any medical authority.

_________________________________ ______________

Physician Signature Date

_________________________________

Physician Name (Printed or Typed)

J-1 PHYSICIAN WAIVER AFFIDAVIT AND AGREEMENT

I, ________________________, being duly sworn, hereby request the Delaware Health and Social Services (DHSS) to review my application for the purpose of recommending waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant to the terms and conditions as follows:

1. I understand and acknowledge that the review of this request is discretionary and that in the event a decision is made not to grant my request, I hold harmless the State of Delaware, DHSS, any and all State employees and/or any and all individuals or organizations involved in the review process from any action or lack of action made in connection with this request.

2. I further understand and acknowledge that the entire basis for the consideration of my request is DHSS’s mission to improve the availability of medical care in areas designated as Health Professional Shortage Areas (HPSA) and Medically Underserved Areas (MUA) by the Secretary of the Department of Health and Human Services.

3. In understand and agree that in consideration for a waiver, which may or may not be granted, I shall render medical care services to patients, including the underserved, for a minimum of forty (40) hours per week with a designated HPSA or MUA in Delaware. Such service shall commence not later than three months (90 days) after I receive notification of approval by the United State Immigration and Naturalization Services (INS) and shall commence for a minimum of three (3) years as required by State policy guidelines.

4. I have incorporated all terms of this Physician J-1 Visa Waiver Affidavit and Agreement into the executed employment contract attached to this request.

5. I further agree that my executed employment contract with the sponsoring site does not contain any provision which modifies or amends any terms of the Program guidelines for Delaware and this Physician J-1 Visa Waiver Affidavit and Agreement.

6. I agree to provide health care services to Medicare, Medicaid and medically underserved patients, without discrimination based upon ability to pay for such services (i.e. self-pay, sliding fee scale, charity care).

7. I agree to provide health services to individuals without discriminating against them because (a) they are unable to pay for those services or (b) payment for those health services will be made under Medicaid and Medicare. I will charge persons receiving services at the usual and customary rate prevailing in the HPSA or MUA in which services are provided, except charges will be on a sliding scale for persons at or below 200 percent of poverty or at no charge for persons unable to pay for these services.

8. I understand I must submit a “No Objection” letter if my home country’s government funded my graduate medical education.

9. I have not been “out of status” (as defined by the Immigration and Naturalization Service of the United States Department of Justice) for more than six (6) months since receiving a visa under 8 U.S.C. 1182 (j) of the Immigration and Nationality Act, as amended.

10. I understand the Declaration of Pending Interested Government and Medical Licensure Affidavit and signed both statements.

11. I expressly understand I am to provide written notification of the specific location and nature of my practice to DHSS at the time I receive notification from INS and I commence rendering services in the HPSA or MUA. I further understand and agree that my relocation from a site approved in the application request to a new site must be approved by DHSS in writing prior to the move.

12. I understand that if I fail to fulfill the terms of my employment contract with the sponsoring site named in this application, I become subject to the two-year foreign residence requirement, and am ineligible to apply for an immigrant visa, permanent residence, or any other change of immigrant status until the two-year foreign residence requirement is met.

13. I expressly understand and acknowledge the scope of the Delaware Conrad State 20/J-1 Visa Waiver Program guidelines and all the information contained in my application request submitted by _____________________ on my behalf.

14. I understand that I am responsible for ensuring that annual reporting requirements are met by myself and my employer in a timely manner in accordance with the Delaware Conrad State 20/J-1 Visa Waiver Program procedures. I agree to fully cooperate with and participate in an exit interview within 90 days prior to completing my three-year practice obligation.

I declare under penalties of perjury that all the information provided to DHSS for the purposes of determining whether it will act as an “Interested Government Agency” is true and correct.

_________________________________ _____________

J-1 Physician Signature Date

_________________________________

J-1 Physician Name (Printed or Typed)

Subscribed to and sworn before me this _____day of _____________, 19____.

_________________________________ _____________

Notary Public Signature Date

J-1 VISA WAIVER APPLICATION CHECKLIST

The requesting J-1 physician applicant must initial that each required enclosure has been included in the application package for review by the Delaware Health and Social Services.

_____ DOS Physician Data Sheet

_____ All IAP-66 Forms and INS Forms 1-94

_____ No Objection Letter (If Required)

_____ Physician Curriculum Vitae

_____ Three (3) Letters of Recommendation

_____ Copy of All Residency/Fellowship Certificates

_____ Copy of Delaware Medical License (Or Proof

of Eligibility)

_____ Copy of Board Eligibility/Certification

_____ Executed Employment Contract

APPENDIX D

CONRAD STATE 20/J-1 VISA WAIVER

SITE APPLICATION EVALUATION WORKSHEET

Review Element Possible Assigned

Weight Points

1. Site Application Documentation: 25

Site data regarding active clients 15

Staffing levels 5

Practice site hours of operation 5

2. Needs Assessment Total: 35

Description of geographic service

area 10

Geographic service area health

resource inventory 5

Documentation of primary care or

specialty shortage 20

3. Retention: 15

Documents short-term plan to

retain J-1 physician 5

Documents long-term plan to

retain J-1 physician at the

end of the three-year obligation. 10

4. Proof of Failed Recruitment

Attempts: 15

Documented proof of failed attempts

to recruit 15

5. Letters of Support: 10

Two letters of support from

community members and/or leaders

in the practice site’s service area

indicate the benefits of, or need

for, the placement of a J-1

physician. 5

One letter from a local public health

official indicates the benefits of,

or need for, the placement of a J-1

physician. 5

Total 100

APPENDIX E

CONRAD STATE 20/J-1 VISA WAIVER

ANNUAL PRACTICE REPORT

1. Name of J-1 Physician: __________________________

Start Date: ______________________

2. Sponsoring Site: _______________________________

Street Address: ________________________________

City: __________ State: ____ Zip: _____ County: ______

Telephone Number:_________ Fax Number: ________

E-Mail Address: _______________________________

Non-Profit: __________ For Profit: _______________

3. Practice Site: __________________________________

Street Address: ________________________________

City: __________ State: ____ Zip: _____ County: _____

4. Contact Person: ________________________________

Street Address: ________________________________

City: __________ State: ____ Zip: _____ County: _____

Telephone Number: _________ Fax Number: _______

E-Mail Address: _______________________________

Type of Service(s) Provided:

Please provide the medical specialties practiced by the J-1 physician, the total hours he/she worked in each specialty and the number of annual visits performed by this physician for each specialty practiced (include all primary care and other medical specialties).

Practice Type	Total Hours/Week	Annual Visits

J-1 Physician’s Hours of Operation:

Indicate the weekly work schedule of the J-1 physician. Include the number of hours (with start and end times) and the primary location (hospital/practice site). The schedule must indicate the time the J-1 physician is actually providing services; do not include travel or on-call time. If the J-1 physician is practicing at more than one location, please complete a schedule for each location.

ite Data Regarding Active Clients:

Provide the total number of active patients at the practice site in the previous calendar year with totals, as applicable, for primary care, specialty care and mental health services.

Total Number of Patients Receiving the Following Medical Services:

Primary Health Care ____ Specialty Care ____ Mental Health Care _____ TOTAL _____

Total Users in Previous Calendar Year Below 200% of Federal Poverty Level ______

Please provide a breakdown of each of the following payor types by age of patient.

AGE GROUP	MEDICAID	MEDICARE	SLIDING FEE SCALE	COMMER-CIAL
Birth – 11 Years	%	%	%	%
12- 18 Years	%	%	%	%
19-62 Years	%	%	%	%
63+ Years	%	%	%	%

This will certify that ___________________________ (name of J-1 physician) provided medical services to patients at the approved health facility site on a full-time basis (minimum forty hour per week) for the time period of ____________ through ____________.

Signature of Applicant Official:_______________________

Title: _________________________ Date: ____________

4 DE Reg. 349 (08/01/00) (FInal)