64W-1.004. Application Requirements

(1) The following Conrad 30 Waiver Program documents must be completed and uploaded as instructed o the Department’s website at http://www.floridahealth.gov/provider-and-partner-resources/community-health-workers/conrad-30-program-j-1-visa/index.html to be evaluated for sponsorship: (a) A Florida DOH Sponsorship Application (DH8006-PHSPM-04/2026) eff. 04-2026, incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19553; (b) A Physician Agreement (DH8007-PHSPM-04/2026) eff. 04-2026, incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19554; (c) Physician Attestation of Exclusivity (DH8008-PHSPM-04/2026) eff. 04-2026, incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19555; (d) Employer Practice Location Attestation(s) (DH8009-PHSPM-04/2026) eff. 04-2026, incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19556; (e) A Specialist Addendum (DH8010-PHSPM-07/2021), incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-13378, is required if the physician is not a Primary Care Physician, as defined in subsection 64W-1.002(6), F.A.C.; (f) A Flex Addendum (DH8011-PHSPM-07/2021), incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-13379, is required for every practice site that is not located in a designated HPSA; (g) Practice Facility Cover Letter; (h) A copy of Employment Contract; (i) Evidence of Shortage Designation Status: A copy of the HRSA “Find Shortage Areas by Address” query result for each practice site location; (j) A copy of the applicant’s clear, active Florida medical license; (k) Physician Curriculum Vitae; (l) A copy of USDOS Form DS-3035 as received from the USDOS. The USDOS Form DS-3035 will not be considered complete without the inclusion of both bar code pages, supplemental pages, and the Physician’s Statement of Reason; (m) A copy of applicable USDOS Form DS-2019/IAP-66, as received from the USDOS; and (n) A copy of USDOS Form G28, as submitted with USDOS Form DS-3035. (2) All Department forms for the Conrad 30 Waiver program will be available on the Department’s website at http://www.floridahealth.gov/provider-and-partner-resources/community-health-workers/conrad-30-program-j-1-visa/index.html.