Ariz. Admin. Code § R9-15-203 - Renewal Application

A. A primary care provider who is expected to complete the initial two years of participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program in the 12 months after April 1, and whose service site has a HPSA score of 14 or more may request to continue participation by submitting a renewal application to the Department by April 1 of each year.

B. To continue or resume participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, the following primary care providers may submit to the Department by October 1 of each year:

1. A renewal application:

a. A primary care provider who has a HPSA score of less than 14 and has completed or will complete the initial two years of participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program before the end of the calendar year; or

b. A primary care provider who participated in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program during the current calendar year and who has completed or will complete three or more years of participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program before the end of the calendar year; or

2. The initial application in R9-15-202(C):

a. A primary care provider who previously participated in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, completed the first two years of participation in the Loan Repayment Program, and is applying to resume participation; or

b. A primary care provider who was previously denied approval to renew participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program because loan repayment funds were not available.

C. A primary care provider applying to continue participation in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable, for an additional year shall submit a renewal application in a Department-provided format to the Department containing:

1. The primary care provider's:

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

b. Existing loan repayment contract number;

2. The name of each service site where the primary care provider provides primary care services, including street address, telephone number, e-mail address, and fax number;

3. Except for a request for change according to R9-15-106, list any changes that may affect the primary care provider's health service priority in R9-15-206 or R9-15-207, as applicable;

4. For each lender receiving loan repayment funds according to the initial application or R9-15-106, the:

a. Lender's name, street address, e-mail address, and telephone number;

b. Street address where the loan repayment funds are sent;

c. Loan identification number;

d. If different from the initial application, the percentage of the loan repayment funds that the primary care provider wants a lender to receive;

e. Current loan balance, including date provided; and

f. Whether the primary care provider requests to continue loan repayment to the lender;

5. If the primary care provider wants to add a qualifying educational loan:

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

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

c. The loan identification number;

d. The original date of the loan;

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

f. The original loan amount;

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

h. The interest rate on the loan;

i. The purpose for the loan;

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

k. If more than one lender is receiving loan repayment funds, the primary care provider shall advise the Department of the percentage of the loan repayment funds that each lender is identified by the primary care provider to receive;

6. For each qualifying educational loan, a copy of the most recent billing statement from the lender;

7. For any qualifying educational loan identified in subsection (C)(5), 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;

8. Whether the primary care provider is subject to a judgment lien for a debt to a federal agency;

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

a. Has defaulted on:

i. A Federal income tax liability,

ii. Any federally-guaranteed or insured student or home mortgage loan,

iii. A Federal Health Education Assistance Loan,

iv. A Federal Nursing Student Loan, or

v. A Federal Housing Authority Loan; or

b. Is delinquent on:

i. A payment for court-ordered child support, or

ii. A payment for state taxes; or

10. If applying to participate in the Rural Private Primary Care Provider Loan Repayment Program, whether the primary care provider is delinquent on payment for state taxes or court-ordered child support;

11. 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) ;

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

13. An attestation that:

a. Except for the circumstances listed in subsection (C)(3), the information in the initial application, other than loan balances and requested repayment amounts, is still current;

b. The Department is authorized to verify all information provided in the renewal application;

c. 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 an additional year for loan repayment of all or part of the qualifying educational loans identified in the renewal application;

d. The primary care provider will charge fees for primary care services established in the sliding-fee schedule according to R9-15-201(A)(2)(d) ; and

e. The information and documentation submitted as part of the renewal application is true and accurate;

14. The primary care provider's signature and date of signature;

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

a. A statement signed by the designee of the governing authority of the service site where the primary care provider provides primary care services that the primary care provider's employment is extended at least for an additional year;

b. The date the primary care provider is expected to end providing primary care services;

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

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

e. Documentation of primary care services provided during the past 12 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;

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

g. An attestation that the service site will comply with the requirements in R9-15-201, including agreeing to notify the Department when the employment status of the primary care provider changes;

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

i. The signature of the designee of the governing authority of the service site and date of signature;

16. If a primary care provider provides 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; and c. Name, title, e-mail address, and telephone number of a contact individual for the critical access hospital;

17. If the primary care provider's employer is not the governing authority of the service site identified in subsection (C)(15), documentation in a Department-provided format, that includes:

a. A statement that the employer will extend the primary care provider's employment for at least an additional year;

b. The date the primary care provider is expected to end providing primary care services at the service site;

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

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

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

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

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

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

18. If more than one employer is identified in subsection (C)(17), the signature and date of signature of the designee of each employer.

D. In addition to the information required in subsection (C), a primary care provider submitting a renewal application shall include the following documentation:

1. Except for a free-clinic, Indian Health Service or tribal facility, or federal prison or state prison, for each service site where the primary care provider provides or will provide primary care services:

a. A copy of the sliding-fee schedule in R9-15-201(A)(2)(d)(i) ,

b. A copy of the sliding-fee schedule policy in R9-15-201(A)(2)(d)(ii), and

c. A copy of the service site's sliding-fee schedule signage in R9-15-201(A)(2)(d)(iii), posted on the premises;

2. If 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; and

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

4. For each lender receiving loan repayment funds, a copy of the most recent billing statement.

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. The Department shall accept a renewal application no more than 30 calendar days before the renewal application submission date required in subsection (A) or (B).

G. If the Department receives a renewal application at a time other than the time stated in subsection (A) or (B), the Department shall return the renewal application to the primary care provider that submitted the renewal application.

H. The Department shall review a primary care provider's renewal application according to R9-15-205.

Notes

Ariz. Admin. Code § R9-15-203

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 R9-15-204 and amended by emergency rulemaking at 28 A.A.R. 1481, effective 11/15/2022. Renumbered and amended from R9-15-204 by emergency rulemaking at 29 A.A.R. 1274, effective 5/14/2023. Renumbered from R9-15-205 and amended by final rulemaking at 29 A.A.R. 3837, effective 12/6/2023.