Document Checklist
June 2015 update
Application is open from March 1st–July 31
st
Applicant and Employer must read the MLRP guide before completing this application at:
http://www.mass.gov/dph/primarycare
Component A & C Applications:
Please use this checklist to ensure your application is complete. Incomplete applications will not be
reviewed.
Health Professional Information Forms completed and signed by the health
professional/applicant
Employer Information Forms – completed and signed by appropriate employer representative
Payor Mix Information Form ( not applicable for correctional facilities)
Health Professional's Qualifying Loan Statement(s).
Health Professional’s Pay Stub
Standard Contract Form
W-9 Form (Verification of Taxation Reporting Information)
Electronic Payment Form (include voided check)
Essay
Copy of the health professional’s current resume or curriculum vitae
Copy of the health professional’s current Massachusetts professional license
Support letter from the practice site (When practice site is different from hiring employer organization a
letter of support is required from the practice site)
Component A & C Applications:
(not required for FQHC applicants)
Copy of non-profit or not-for-profit documentation for the health care organization/employer or practice site
A copy of your practice site’s sliding fee scale and policy. Your site’s sliding fee scale should reflect current
federal poverty guidelines. Current federal guidelines can be found here:
http://aspe.hhs.gov/poverty/
Component A Applications:
Proof of U.S. citizenship for the health professional (provide a copy of passport or birth certificate)
Component C Applications:
Either proof of U.S. citizenship (copy of passport or birth certificate)
OR proof of legal residency
(provide a copy of both sides of the permanent resident card)
Documentation that greater than 30% of the patients served by the site are located in HPSAs or
MUAs (not required for FQHC applicants)
Application Submission Information:
Please submit ONE completed original application. Use
BLUE ink for all signatures. Please be sure to check off
each applicable “Document Checklist” item. Submit documents in the order that they appear on the checklist.
Your completed “Document Checklist” should be the first page to your application.
Keep a copy of the entire application for your records.
Mail to: Nicole Watson
MDPH – Health Care Workforce Center
250 Washington Street, 5
thFloor
Health Professional Information Form
Application is for: ____ComponentA ____ComponentC
Name: (First) (Middle Initial) (Last)
Home Address: Street City Zip Code
Residence prior to health professional education: City State
Sex: M F Other Decline to answer
Preferred Phone #: Work Phone #:
Preferred E-mail:
Ethnicity:
Are you Hispanic/Latino/Spanish?_____Yes _____No _____Decline to answer
What race(s) do you most identify with? Check all that apply:
_____Asian _____White _____Native Hawaiian/Other Pacific Islander _____Black _____American Indian/Alaskan Native _____Decline to answer
Section B: Professional Information
Profession: (circle one) Applicants must have completed a course of study required to practice independently without supervision. CNM Certified Nurse-Midwife
DD General Dentist (D.D.S. or D.M.D.)
DH Dental Hygienist
DO* Doctor of Osteopathic Medicine
HSP Health Service Psychologist (Ph.D. or equivalent; Clinical & Counseling)
LADC 1 Licensed Alcohol and Drug Counselor (Master’s level)
LiCSW Licensed Clinical Social Worker (master’s / doctoral degree in social work)
LPC Licensed Professional Counselor
MD* Doctor of Allopathic Medicine
MFT Marriage and Family Therapist(master’s / doctoral degree with a major study in marriage and family therapy) MHC Mental Health Counselor (master’s / doctoral degree with a major study in counseling)
NPΩ Primary Care Certified Nurse Practitioner PAΩ Primary Care Physician Assistant PD Pediatric Dentist
PharmD Pharmacist
PNS Psychiatric Nurse Specialist
RN Registered Nurse
* Family Medicine (& Osteopathic General Practice), Internal Medicine; Pediatrics; Ob-Gyn; Geriatrician; Psychiatrist Ω Adults; Family; Pediatrics; Psychiatry/Mental Health; Geriatrics; Women’s Health
Specialty: (e.g. Family Medicine) Board Certified? ____Yes ____No
Other professional certification(s):
School attended for health professional training: Year of graduation (YYYY):
Name of residency training program: Date of completion (MM/YYYY):
Undergraduate college or university: Year of graduation (YYYY):
Section C: Employment Information Practice Site Name:
Practice Site Address: Street City Zip Code
Starting Date of Employment:
Please indicate the # of hours you are scheduled to work per week: _________ hrs/wk
Health Professional Information Form
In addition to English, indicate language(s), you speak with sufficient fluency to provide adequate health care: How did you hear about the program?
Massachusetts Department of Public Health/Primary Care Office Website College/University Career Services
Residency Employer Colleague
Presentation at College / University Internet Search Other__________________
Have you previously received award(s) from the MLRP? ______Yes ______No
Do you have a current commitment to any of the following programs: Yes No
*Please indicate inmonths the time commitment remaining.
MLRP: Yes No Time Commitment Remaining:__________________
Mass League of Community Health Centers: Yes No Time Commitment Remaining:__________________
National Health Service Corp: Yes No Time Commitment Remaining:__________________
UMass Learning Contract: Yes No Time Commitment Remaining:__________________
Kraft Family National Center for Leadership & Training in Community Health:
Yes No Time Commitment Remaining:__________________
Other: __________________________________________ Time Commitment Remaining:__________________
Provide affirmation of the eligibility criteria by initialing the following items:
Statement Affirmation(Initials)
I, the applicant, am a United States Citizen (required for A; either US Citizen or legal permanent resident is required for C).
I, the applicant, am a legal permanent resident (required for "C" if not a US Citizen).
I have a current and non-restricted license to practice in the Commonwealth of Massachusetts, appropriate for the health profession discipline.
I agree to provide primary care services to any individual seeking care and will not discriminate on the basis of the patient’s ability to pay for care or on the basis that payment for care will be made pursuant to public payor programs such as: Medicaid/MassHealth, the State Children’s Health Insurance Program, Commonwealth Care Programs, and/or through the sliding fee scale. (refer to Payor Mix section)
I do not have a judgment lien against my property for a debt to the United States.
DECLARATION: This Declaration form must be signed by the Health Professional Applicant
All of the information on this application is truthful and accurate. I understand that knowingly submitting false information will void this application and may be considered a breach of my Massachusetts Loan Repayment Program (MLRP) for Health Professionals contract. I agree to sign a contract with the Massachusetts Department of Public Health/Primary Care Office to provide two years of full-time service or equivalent in part-time service at an eligible Employer Healthcare
Organization according to the specifications in the MLRP Program Guide. By signing this application, I agree to all of the conditions stipulated in the MLRP Program Guide.
_____________________________________________ _______________
Applicant (Health Professional) Signature Date
(First) ________________________________ Middle Initial ________ (Last) ______________________
Print Name
Employer Information Form
Employer Healthcare Organization:
Employer Address: Street City Zip Code
Employer Contact Name: Title:
Employer Phone #: Medicaid Billing #:
Employer Contact Email:
Healthcare Organization Employer Qualifications
*
Type of Shortage Designation: ______________________________________ HPSA # / MUA #: _______________________
_______PC-HPSA # HPSA Score: _________
*
Shortage designation information can be found at:http://www.hrsa.gov/shortage/Name of Applicant/ Health Professional: (First) (Middle Initial) (Last)
# hours /week of direct out-patient care: # hours /week of non-patient care duties:
Describe the need for this health professional at your organization and the type of patients/population he/she will care for (eg. homeless, LGBT):
If the site is supporting more than one health professional application for this year, please indicate the priority preference of this application relevant to other applications submitted by the site for this year.
Circle one:
1
2
3
Employer Information Form
Provide assurance of employer eligibility criteria by initialing the following items as appropriate:
The applicant Employer Healthcare Organization certifies that it meets the eligibility requirements and
has provided truthful information regarding the employment of the applicant and understands the need
for compliance with all specifications set forth by the Massachusetts Loan Repayment Program
(MLRP) for Health Professionals Program Guide.
The Employer Healthcare Organization certifies that loan repayment funds will not be used to supplant
an MLRP provider's expected wages or benefits as compared to other similarly qualified and situated
employees.
As a representative of ________________________________________________ I recommend this
applicant for the MLRP.
(Employer Healthcare Organization
)SIGNATURE OF AUTHORIZED REPRESENTATIVE:
_______________________________________________
______________________
Signature
Date
(First)_______________________________ (Middle initial)______ (Last)________________________
Print Name & Title
Rev. 6/15 2 of 3 Employer Information Form
Statement Affirmation
(Initials) Health professional applicant will provide services in a public or a non-profit organization that holds
any necessary MDPH licenses.
The employer healthcare organization (and billing entity if different) is certified as a provider by MassHealth and complies with the regulations governing MassHealth; accepts Medicare; and accepts patients enrolled in Commonwealth Care programs.
The employer healthcare organization (and billing entity if different) is certified as a provider by MassHealth and has a rate established by the Division of Health Care Finance and Policy; and is in compliance (good standing) with MassHealth regulations and certifications.
Applicant employer healthcare organization (and billing entity if different) must charge for their professional services at the usual and customary prevailing rates in the area in which such services are provided, except if a person is unable to pay the charge, such person shall be charged at a reduced rate using a schedule of fees for those at various income levels and will display a notice of availability of discounted fees for the uninsured (i.e. sliding fee scale) or not charged any fee.
The employer healthcare organization must provide documentation of fee schedule or sliding fee scale and policy.
The employer health care organization agrees to provide primary care services as provided by the eligible health professionals and defined in the Program Guide, to any individual seeking care. MLRP awardees and employer (and site, if different) must agree not to discriminate on the basis of the patient’s ability to pay for such care or on the basis that payment for such care will be made pursuant to Medicaid/MassHealth, Medicare, the State Children’s Health Insurance Program and/or the Commonwealth Care Programs and/or through the sliding fee scale. A support letter from the employment site if different than the hiring employer organization (see the section Obligations of the Employer Healthcare Organization in the Program Guide) is attached, if appropriate.
Employer Information Form
Payor Mix Information
Provide the following patient payor mix percentage. This payor mix information should come
from agency billing or financial data.
Note: refer to health insurance options for low income residents at
https://www.mahealthconnector.org/
.
% of Patient Population
Medicaid (MassHealth) only
Medicaid /Medicare Dual Eligible
Commonwealth Care
Health Safety Net (Free Care)
Commonwealth Choice
Children’s Medical Security
Medicare only
Self Pay
Other Uninsured
Please state from where the above data was derived, and the time period it represents.
Signature of Authorized Representative: __________________________________________
Signature
First_______________ Middle initial ____Last___________
Print Name
__________________________________________
Print Title
Health Professional's Qualifying Loan Statement
Please attach a copy of your:
1) Student loan statement (must be current and complete)
Loan statement should be from the month previous to, or month of, this
application.
Must include relevant full Name and Address
HIGHLIGHT each outstanding loan on the loan statements.
Below please list each student loan dollar amount
2) Pay Stub
Include a copy of a pay stub from your practice site from month previous to, or
month of, this application.
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Student loan carrier: ________________________________ Loan amount $_________________
Total loan amount$_________________
What is your current total annual salary? $_________________
What is the amount you are requesting from the MLRP? $_________________
Amount awarded by the MLRP will not exceed total outstanding loan amount.
Standard Contract Form
Name of Applicant (Health Professional/Contractor):
Home Address: Street City State Zip
Name of Applicant’s Practice Site:
Practice Site Address: Street City State Zip
MDPH Use Only
: HPSA#____________________CONTRACT START DATE: ___________ CONTRACT END DATE: ____________ Vendor Code:
_____________________ Award Amount:
$___________________
Rev.6/15 Standard Contract Form
CERTIFICATIONS: The “Effective Date” of this Contract shall be the latest date this Contract was signed by an
authorized signatory of the Massachusetts Department of Public Health. By executing this Contract, the Contractor makes, under the pains and penalties of perjury, all certifications required under the terms of the Program Guide. Additionally, the Contractor certifies he/she has not been in bankruptcy and/or receivership within the last three calendar years, and certifies that he/she will immediately notify the Department in writing if there is any risk to the solvency of the Contractor that may impact the Contractor’s ability to timely fulfill the terms of this Contract. The Contractor shall affirmatively disclose the details of any pertinent judgment, criminal conviction, investigation or litigation pending against the Contractor.
The Contractor agrees to all terms governing performance of this Contract, as stated in the Program Guide, the Commonwealth Terms and Conditions, and any additional negotiated performance or budget provisions. The terms of this Contract shall survive its termination for the purpose of resolving any claim, dispute or other Contract action, or for effectuating any negotiated representations and warranties.
By executing this Contract, the Contractor under the pains and penalties of perjury, makes all certifications required under the certifications listed below, and has provided all required documentation, or shall provide any required documentation upon request, and the Contractor agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached to this Contract or incorporated by reference herein the Program Guide, the Contractor’s response to the Program Guide, and any additional non-conflicting negotiated provisions:
The Contractor is qualified and shall at all times remain qualified to perform this Contract; that performance shall be timely and meet or exceed industry standards, including obtaining requisite licenses, registrations, permits and resources for performance.
The Contractor shall comply with the terms of the Program Guide, and any additional negotiated provisions for this Contract.
Health Professional/Contractor SIGNATURE:
X:_____________________________ Date:________
(Signature and Date Must Be Handwritten At Time of Signature)
Print Name: _______________________________ Print Title: _________________________________
MDPH Representative Signature:
X: __________________________ Date:_________ Print Name: ____Julia Dyck___________________ Print Title: ____Director, HCWC_______________
Department MMARS Alpha Code and Name: MDPH
Business Mailing Address: 250 Washington St, 5thFl., Boston, MA 02108
Contract Manager: Nicole Watson
E-Mail Address: Nicole.watson@state.ma.us Phone: 617-624-6051
Fax: 617-624-6062 TTY:
MMARS Doc ID(s):
Program Guide/Procurement or Other ID Number(if applicable):