Ariz. Admin. Code § R9-15-202 - Initial Application

A. Except as provided in R9-15-203(A), to apply to participate in the Primary Care Provider Loan Repayment Program or Rural Health Care Provider Loan Repayment Program, a primary care provider who has not previously participated in the Primary Care Provider Loan Repayment Program or Rural Health Care Provider Loan Repayment Program shall submit an initial application to the Department by June 1 of each year.

B. A primary care provider, who submitted an initial application to the Department according to subsection (A) but was not approved to participate in the LRP during the June allocation process according to subsection (H) or because loan repayment funds were not available, may reapply during the October allocation process of the same calendar year by submitting a supplemental initial application by October 1.

C. B. A primary care provider applying to participate in the Primary Care Provider Loan Repayment Program or Rural Health Care Provider Loan Repayment Program shall submit to the Department an initial application containing:

1. The following information in a Department-provided format:

a. The primary care provider's:

i. Name, home address, telephone number, and e-mail address;

ii. Social Security number; and

iii. Date of birth;

b. The name, street address, e-mail address, and telephone number of the employer or prospective employer where the primary care provider provides or will provide primary care services while participating in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, including the dates that the primary care provider is expected to start and end providing primary care services;

c. The name, street address, and telephone number for each place of employment with a health professional or a health care institution, including a name, title, e-mail address, and telephone number of a contact individual for the place of employment;

d. Type of license and, if applicable, certification held by the primary care provider;

e. Type of medical, dental, or behavioral health specialty or subspecialty, if applicable;

f. If an advanced practice provider, a behavioral health care provider, or a pharmacist, whether the primary care provider holds national certification;

g. Whether the primary care provider will provide primary care services full-time or half-time;

h. Whether the primary care provider is an Arizona resident;

i. Whether the primary care provider has any health professional service obligation;

j. Whether the primary care provider has defaulted in a health professional service obligation and, if so, a description of the circumstances of the default;

k. Whether the primary care provider is subject to a judgment lien for a debt to a federal agency and, if so, a description of the circumstances of the default;

l. If applying to participate in the Primary Care Provider Loan Repayment Program, whether the primary care provider:

i. Has defaulted on:

(1) A Federal income tax liability,

(2) Any federally-guaranteed or insured student loan or home mortgage loan,

(3) A Federal Health Education Assistance Loan,

(4) A Federal Nursing Student Loan, or

(5) A Federal Housing Authority Loan; or

ii. Is delinquent on:

(1) A payment for court-ordered child support, or

(2) A payment for state taxes; or

m. If applying to participate in the Rural Private Primary Care Provider Loan Repayment Program, whether the primary care provider is delinquent on payment for:

i. State taxes, or

ii. Court-ordered child support;

n. Whether the primary care provider has experience providing primary care services to a medically underserved population;

o. Whether the primary care provider is providing services at a critical access hospital and primary care services at a service site according to R9-15-201(A)(1)(g) ;

p. Whether the primary care provider agrees to allow the Department to submit supplemental requests for additional information or documentation in R9-15-205 ;

q. An attestation that:

i. The Department is authorized to verify all information provided in the initial application;

ii. The primary care provider is applying to participate in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable, for two years with the State of Arizona for loan repayment of all or part of qualifying educational loans identified in the initial application;

iii. The qualifying educational loans identified in the initial application were for the costs of health professional education, including reasonable educational expenses and reasonable living expenses, and do not reflect a loan for other purposes;

iv. The primary care provider will charge fees for primary care services according to the sliding-fee schedule in R9-15-201 (A)(1)(f) ; and

v. The information and documentation submitted as part of the initial application is true and accurate; and

r. The primary care provider's signature and date of signature.

2. Documentation that meets the requirements in A.R.S. § 41-1080;

a. U.S. passport, current or expired;

b. Birth certificate;

c. Naturalization documents; or

d. Documentation as a U.S. National;

3. A copy of the primary care provider's Social Security card;

4. A copy of the primary care provider's current driver's license;

5. Documentation showing Arizona residency according to A.R.S. § 15-1802;

6. Documentation showing completion of graduate studies issued by an accredited educational agency;

7. A copy of the primary care provider's current Arizona licenses or, if applicable, certificates in a health profession licensed under A.R.S. Title 32;

8. If a physician, documentation showing the physician:

a. Has completed:

i. A professional residency program in family medicine, pediatrics, obstetrics-gynecology, internal medicine, or psychiatry; or

ii. A fellowship, residency, or certification program in geriatrics; and

b. Is either board certified or board eligible in:

i. Family medicine,

ii. Internal medicine,

iii. Pediatrics,

iv. Geriatrics,

v. Obstetrics-gynecology, or

vi. Psychiatry;

9. If the primary care provider is a physician assistant practicing as a behavioral health care provider, a copy of the primary care provider's national certificate issued by the National Commission on Certification of Physician Assistants in Psychiatry;

10. For a primary care provider who has completed health service experience to a medically underserved population, a written statement for each service site where the primary care provider provided primary care services that includes:

a. The service site's name, street address, e-mail address, and telephone number;

b. The number of clock hours completed;

c. A description of the primary care services provided;

d. The primary care service start and end dates;

e. The service site's federal or state designation as medically underserved or as a HPSA; and

f. The name and signature of an individual authorized by the governmental agency, the accredited educational institution, or the non-profit organization and the date signed;

11. If applicable, documentation showing that the primary care provider's health professional service obligation owed under contract with a federal, state, or local government or another entity will be completed before beginning a period of primary care services under the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable;

12. For each qualifying educational loan:

a. The following information provided in a Department-provided format:

i. The lender's name, street address, e-mail address, and telephone number;

ii. The street address where the loan repayment funds are sent;

iii. The loan identification number;

iv. The original date of the loan;

v. The primary care provider's name as it appears on the loan contract;

vi. The original loan amount;

vii. The current balance of the loan, including the date provided;

viii. The interest rate on the loan;

ix. The purpose for the loan;

x. The month and year of the start and the end of the academic period covered by the loan; and

xi. The percentage of the loan repayment funds the primary care provider establishes for a lender if more than one lender is receiving loan repayment funds;

b. A copy of the most recent billing statement from the lender; and

c. Documentation from the lender or the National Student Loan Data System established by the U.S. Department of Education verifying that the loan is a qualifying educational loan;

13. For each service site where a primary care provider will provide primary care services, a copy of a contract, a letter verifying employment, or a letter of intent to hire signed by the primary care provider and the designee of the governing authority from the service site where the primary care provider will provide primary care services including:

a. The name, street address, e-mail address, and telephone number of the service site;

b. The name of a contact individual for the service site;

c. Whether the primary care provider is providing primary care services full-time or half-time; and

d. If currently employed, the employment start date;

14. If more than one service site governing authority is identified in subsection (B)(1)(b), the signature and date of signature of the designee of the governing authority of each service site on the document provided according to subsection (C)(13);

15. For each service site where the primary care provider will provide primary care services, documentation, in a Department-provided format, that includes:

a. Name, street address, telephone number, e-mail address, and fax number of the service site;

b. Whether the primary care provider is providing primary care services full-time or half-time;

c. The number of primary care service hours per week the primary care provider is expected to provide;

d. The dates that the primary care provider is expected to start and end providing primary care services;

e. If a primary care provider will provide telemedicine, the number of telemedicine hours the primary care provider is expected to provide;

f. Service site practice type;

g. Whether the service site:

i. Complies with the requirements in A.R.S. § 36-2172(B)(2), or

ii. Is a private practice service site according to A.R.S. § 36-2174;

h. Except for a free-clinic or Indian Health Service or tribal facility, whether the service site accepts Medicare, AHCCCS, and a qualifying health plan;

i. Except for a free-clinic or Indian Health Service or tribal facility, if the service site accepts:

i. Medicare, the service site's Medicare identification number;

ii. AHCCCS, the service site's AHCCCS provider number; and

iii. Qualifying health plan, the service site's qualifying health plan provider number;

j. Distance from the nearest sliding-fee schedule clinic having the same practice type;

k. Documentation of a service site's HPSA designation and HPSA score, dated within 30 calendar days before the initial application submission date;

l. Documentation of the primary care services provided by the service site during the past 24 months including the:

i. Number of encounters,

ii. Number of AHCCCS encounters,

iii. Number of Medicare encounters,

iv. Number of self-pay encounters on sliding-fee schedule, and

v. Number of encounters free-of-charge; and

m. The name, title, e-mail address, and telephone number of a contact individual for the service site;

16. An attestation, including the signature of the designee of the governing authority of the service site and date of signature, that the service site shall comply with the requirements in R9-15-201, including agreeing to notify the Department when the employment status of the primary care provider changes;

17. If the primary care provider will provide services at a critical access hospital according to R9-15-201(A)(1)(g), documentation in a Department-provided format that includes the:

a. Name, street address, telephone number, e-mail address, and fax number of the critical access hospital;

b. Number of service hours per week that the primary care provider is expected to provide at the critical access hospital;

c. Name, title, e-mail address, and telephone number of a contact individual for the critical access hospital;

18. Except for a free-clinic, Indian Health Service or tribal facility, or federal prison or state prison, a copy of the service site's:

a. Sliding-fee schedule in R9-15-201(A)(2)(d)(i) ,

b. Sliding-fee schedule policy in R9-15-201(A)(2)(d)(ii) ,

c. Sliding-fee schedule signage in R9-15-201(A)(2)(d)(iii) posted on the premises;

19. If the service site is a free-clinic, a copy of the policy in R9-15-201(A)(2)(f) that the free-clinic provides primary care services to individuals at no charge;

20. If the primary care provider's employer is not the governing authority of the service site identified in subsection (B)(13), documentation in a Department-provided format that includes:

a. An attestation that the employer will comply with the requirements required in R9-15-201(A)(2), including agreeing to notify the Department when the employment status of the primary care provider changes;

b. The name, title, e-mail address, and telephone number of a contact individual for the employer;

c. Whether the employer:

i. Complies with the requirements in A.R.S. § 36-2172(B)(2), or

ii. Is a private practice service site in A.R.S. § 36-2174;

d. Whether the primary care provider is or will be providing primary care services full-time or half-time;

e. The dates that the primary care provider is expected to start and end providing primary care services; and

f. The employer's signature and date of signature; and

21. If more than one employer is identified in subsection (B)(20), the signature and date of signature of the designee of the employer of each service site.

D.C. If the primary care provider provided documentation of an existing health professional service obligation under subsection (B)(11), the applicant shall submit to the Department documentation demonstrating the completion of the health professional service obligation before the start of the primary care provider's loan repayment contract with the Department.

E. A primary care provider shall execute any document necessary for the Department to access records and acquire information necessary to verify information provided by the primary care provider.

F.D. The Department shall accept an initial application no more than 45 calendar days before the initial application submission date required in subsection (A).

G.E. If the Department receives an initial application from a primary care provider at a time other than the time stated in subsection (A), the Department shall return the initial application to the primary care provider.

H.F. The Department shall not approve a primary care provider's initial application during a June allocation process if:

1. The primary care provider's service site employs two other primary care providers approved to participate in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable, during the June allocation process, or

2. The primary care provider's employer employs four other primary care providers approved to participate in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable, during the June allocation process.

I.G. The Department shall review a primary care provider's initial application according to R9-15-205.

Notes

Ariz. Admin. Code § R9-15-202

New Section made by final rulemaking at 7 A.A.R. 2823, effective August 9, 2001 (Supp. 01-2). Adopted by exempt rulemaking at 22 A.A.R. 851, effective 4/1/2016. Renumbered from R9-15-203 and amended by emergency rulemaking at 28 A.A.R. 1481, effective 11/15/2022. Amended by emergency rulemaking at 29 A.A.R. 1274, effective 5/14/2023. Renumbered from R9-15-203 and amended by final rulemaking at 29 A.A.R. 3837, effective 12/6/2023.