Ariz. Admin. Code § R9-15-303 - Renewal Application

A. An applicant who is expected to complete the initial two years of participation in the Behavioral Health Care Provider Loan Repayment Program in the 12 months after January 15 of each year, and whose service site is the Arizona State Hospital or has a HPSA score of 14 or more may request to continue participation by submitting to the Department a renewal application in subsection (B) by January 15 of the same year.

B. An applicant applying to renew participation in the Behavioral Health Care Provider Loan Repayment Program for an additional year shall submit to the Department:

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

a. The applicant's name, home address, telephone number, and e-mail address;

b. The existing behavioral health loan repayment contract number;

c. The name of each service site where the applicant provides behavioral health services, including street address, telephone number, e-mail address, and fax number;

d. Except for a request for a change made according to R9-15-106, a list of any changes that may affect the applicant's health service priority in R9-15-306 ;

e. For each lender receiving loan repayment funds specified according to R9-15-302(B)(1)(f) or R9-15-106:

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

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

iii. The loan identification number;

iv. If different from the information specified according to R9-15-302(B)(1)(f) or R9-15-106, the percentage of the loan repayment funds that the applicant wants the lender to receive;

v. Current loan balance, including date provided; and

vi. Whether the applicant requests to continue loan repayment to the lender;

f. If the applicant wants to add a qualifying educational loan:

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

ii. The address where the 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 loan repayment funds that the applicant wants the lender to receive;

g. Whether the applicant agrees to allow the Department to submit supplemental requests for additional information or documentation in R9-15-305 ;

h. The applicant's attestation that:

i. Except for the circumstances listed in subsection (C)(1)(d), the information specified according to R9-15-302(B), other than loan balances and requested repayment amounts, is still current;

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

iii. The applicant is applying to participate in the Behavioral Health Care Provider Loan Repayment Program for an additional year for loan repayment of all or part of the qualifying educational loans identified according to subsection (B)(1)(e) or (f); and

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

i. Whether the applicant is delinquent on payment of:

i. State taxes,

ii. Court-ordered child support, or

iii. A federal income tax liability;

j. 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

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

2. To document the total time that an applicant had health service experience to a medically underserved population, including the time during the period the applicant provided services during the initial two years of participation in the Behavioral Health Care Provider Loan Repayment Program, a written statement for each service site where the applicant provided services that includes:

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

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

c. The number of clock hours completed:

i. Before participation in the Behavioral Health Care Provider Loan Repayment Program,

ii. During the initial two years of participation in the Behavioral Health Care Provider Loan Repayment Program, and

iii. In total at the service site;

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; and

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

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

4. For any qualifying educational loan identified in 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; and

5. For each service site where the applicant provides behavioral health services, an attestation that includes:

a. A statement that the applicant's employment is extended at least for an additional year;

b. The date the applicant started and the date the applicant is expected to end providing behavioral health services;

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

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

e. If the applicant will provide telemedicine, the number of telemedicine hours the applicant is expected to provide;

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

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

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

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

D. If the Department receives a renewal application at a time other than the date stated in subsection (A), the Department shall return the renewal application to the applicant.

E. The Department shall review a renewal application according to R9-15-305.

Notes

Ariz. Admin. Code § R9-15-303

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. 852, effective 4/1/2016. Adopted by emergency rulemaking at 28 A.A.R. 3684, effective 11/15/2022. Renumbered and amended from R9-15-304 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.