Ariz. Admin. Code § R9-15-302 - Initial Application

A. To apply to participate in the Behavioral Health Care Provider Loan Repayment Program, an applicant who has not previously participated in the Behavioral Health Care Provider Loan Repayment Program shall submit an initial application in subsection (B) to the Department by March 1 of each year.

B. An applicant applying to participate in the Behavioral Health Care Provider Loan Repayment Program shall submit to the Department:

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

a. The applicant's name, home address, telephone number, e-mail address, Social Security number, and date of birth;

b. The name of each service site where the applicant provides behavioral health services and will continue to provide behavioral health services while participating in the Behavioral Health Care Provider Loan Repayment Program;

c. If applicable, the type of license or certification held by the applicant, including, if applicable, the applicant's National Provider Identifier (NPI) number;

d. The type of behavioral health specialty or subspecialty, if applicable;

e. Whether the applicant:

i. Provides behavioral health services full-time;

ii. Is an Arizona resident;

iii. Has any health professional service obligation;

iv. Has defaulted in a health professional service obligation and, if so, a description of the circumstances of the default;

v. Has experience providing behavioral health services to a medically underserved population; and

vi. Agrees to allow the Department to submit supplemental requests for additional information or documentation in R9-15-306 ;

f. For each qualifying educational loan:

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

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

iii. The loan identification number;

iv. The original date of the loan;

v. The applicant'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 behavioral health loan repayment funds the applicant establishes for a lender if more than one lender is receiving behavioral health loan repayment funds;

g. An attestation that:

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

ii. The applicant is applying to participate in the Behavioral Health Care Provider Loan Repayment Program for two years with the State of Arizona for loan repayment of all or part of qualifying educational loans identified according to subsection (B)(1)(f);

iii. The qualifying educational loans identified according to subsection (B)(1)(f) 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; and

iv. The information and documentation submitted is true and accurate;

h. Whether the applicant is delinquent on:

i. State taxes,

ii. Court-ordered child support, or

iii. A federal income tax liability,

i. Whether the applicant has defaulted on:

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

ii. A Federal Health Education Assistance Loan,

iii. A Federal Nursing Student Loan, or

iv. A Federal Housing Authority Loan; and

j. The applicant's signature and date of signature;

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

3. A copy of the applicant's Social Security card;

4. A copy of the applicant's current driver's license;

5. If applicable, documentation showing Arizona residency according to A.R.S. § 15-1802;

6. Documentation showing graduation or the completion of the final year of a course of study from an accredited health professional school;

7. If applicable, documentation showing completion of graduate studies issued by an accredited educational agency;

8. If applicable, a copy of the applicant's current Arizona license under A.R.S. Title 32 in a health profession;

9. If a physician, documentation showing that the physician has completed a professional residency program or certification program in behavioral health;

10. For each qualifying educational loan identified according to subsection (B)(1)(f), a copy of the most recent billing statement from the lender;

11. For each qualifying educational loan identified according to subsection (B)(1)(f), 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;

12. For an applicant who has completed health service experience to a medically underserved population, a written statement for each applicable service site where the applicant provided services that includes:

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

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

c. The number of clock hours completed;

d. A description of the services provided;

e. The service start date and end date;

f. The service site's federal or state designation as medically underserved:

g. The name and signature of an individual authorized by the governing authority of the service site and the date signed;

13. If applicable, documentation showing that the applicant'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 providing behavioral health services under the Behavioral Health Care Provider Loan Repayment Program;

14. A copy of a contract or a letter verifying employment for each service site where an applicant provides behavioral health services that includes:

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

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

c. That the applicant is providing behavioral health services full-time;

d. The employment start date;

e. For a contract, the signature and date of signature of the applicant and a designee of the governing authority of the service site; and

f. For a letter verifying employment, the signature and date of signature of a designee of the governing authority of the service site;

15. Documentation from the service site that includes:

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

i. The name, street address, telephone number, and fax number of the service site;

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

iii. A statement that the applicant is providing behavioral health services full-time;

iv. The number of behavioral health service hours per week the applicant is expected to provide;

v. The date that the applicant started providing behavioral health services at the service site;

vi. Service site's health care institution class or subclass, as specified in A.A.C. R9-10-102 ;

vii. Whether the service site is a public or non-profit service site according to A.R.S. § 36-2175;

viii. An attestation that the service site complies with the requirements in R9-15-301(A)(1)(d) and (e) and (2) ; and

ix. The name and signature of a designee of the governing authority of the service site and the date signed; and

b. If applicable, documentation of the service site's HPSA designation and HPSA score, dated within 30 calendar days before the date of submission; and

16. If the applicant's employer is not the governing authority of the service site identified in subsection (B)(1)(b), an attestation from the employer that includes:

a. The name and mailing address of the employer;

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

c. The dates that the applicant started and, if applicable, is expected to end providing behavioral health services for the employer;

d. The employer's agreement to notify the Department when the employment status of the applicant changes, as required in R9-15-301(A)(2) ;

e. A statement that the information submitted in the attestation is true and accurate; and

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

C. If the applicant provided documentation of an existing health professional service obligation under subsection (B)(13), the applicant shall submit to the Department documentation demonstrating the completion of the health professional service obligation before the start of the applicant's behavioral health loan repayment contract with the Department.

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

E. If the Department receives an initial application from an applicant at a time other than the time specified in subsection (A), the Department shall return the initial application to the applicant.

F. Except for when the service site is identified as the Arizona State Hospital, the Department shall not approve an applicant's initial application during a March allocation process if:

1. The applicant's service site employs two other applicants approved to participate in the Behavioral Health Care Provider Loan Repayment Program during the March allocation process, or

2. The applicant's employer employs four other applicants approved to participate in the Behavioral Health Loan Care Provider Repayment Program during the March allocation process.

G. The Department shall review an applicant's initial application according to R9-15-305.

Notes

Ariz. Admin. Code § R9-15-302

New Section made by final rulemaking at 7 A.A.R. 2823, effective August 9, 2001 (Supp. 01-2). Repealed by exempt rulemaking at 22 A.A.R. 851, effective 4/1/2016. Adopted by emergency rulemaking at 28 A.A.R. 3684, effective 11/15/2022. Amended by emergency rulemaking at 29 A.A.R. 1274, effective 5/14/2023. New Section made by final rulemaking at 29 A.A.R. 3837, effective 12/6/2023.