Ariz. Admin. Code § R9-15-204 - Supplemental Initial Application

A. If a primary care provider submits an initial application to the Department according to R9-15-202 and is not approved to participate in the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program, as applicable, during the initial application allocation process, the primary care provider may reapply during the October allocation process by submitting a supplemental initial application according to subsection (B) by October 1 of the same calendar year.

B. A primary care provider reapplying for an October allocation process according to R9-15-202(A) shall submit a supplemental initial application in a Department-provided format to the Department that contains:

1. The primary care provider's name, home address, telephone number, and e-mail address;

2. The primary care provider's attestation that:

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

b. The primary care provider is applying to participate in either the Primary Care Provider Loan Repayment Program or Rural Private Primary Care Provider Loan Repayment Program for two years for loan repayment of all or part of qualifying educational loans identified in the initial application;

c. The initial application submitted prior to the October allocation process of the same calendar year is still accurate, except for loan or lender information;

d. The primary care provider will charge fees for primary care services according to R9-15-201(A)(2)(d) ;

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

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

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

3. For each primary care provider lender, the following:

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

b. The loan identification number; and

c. The loan balance including principal and interest;

4. An attestation from the designee of the governing authority of the service site that includes:

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

b. 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 in A.R.S. § 36-2174;

c. The service site provider agrees to comply with the requirements in R9-15-201, including agreeing to notify the Department when the employment status of the primary care provider changes;

d. Whether the primary care provider is 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;

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

g. The information submitted as part of the supplemental initial application is true and accurate; and

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

5. If the primary care provider's employer is not the governing authority of the service site identified in subsection (B)(4), an attestation from the employer that includes:

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

b. Whether the employer:

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;

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

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

e. 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;

f. The information submitted as part of the supplemental initial application is true and accurate; and

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

6. A copy of the most recent billing statement for the loans listed on the initial application; and

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

C. If more than one service site governing authority is identified in subsection (B)(4), the signature and date of signature of the designee of the governing authority of each service site.

D. The Department shall accept a supplemental initial application no more than 30 calendar days before the supplemental initial application submission date required in subsection (A).

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

Notes

Ariz. Admin. Code § R9-15-204

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 R9-15-205 and amended by emergency rulemaking at 28 A.A.R. 1481, effective 11/15/2022. Renumbered and amended from R9-15-203 by emergency rulemaking at 29 A.A.R. 1274, effective 5/14/2023. Amended by final rulemaking at 29 A.A.R. 3837, effective 12/6/2023.