R434-100-5. Requests

(1) The health care facility or the physician shall submit to the department a written request for a Conrad 30 J-1 visa waiver. (2) Each request for a Conrad 30 J-1 visa waiver shall include: (a) if the request is from a health care facility: (i) the specialty of physician that the facility has been unable to recruit; (ii) documentation that the facility implements a sliding fee scale, payment schedule, or similar method that demonstrates that the facility provides discounts to medically indigent patients; and (iii) an assurance letter that neither the health care facility nor any principal of the facility is under investigation, probation, or restriction for: (A) Children's Health Insurance Program, Medicaid, or Medicare fraud; (B) violation of Division of Professional Licensing statute or rules; or (C) any other violation of law that may indicate that a waiver of the two-year home residency requirement may not be in the public interest; (b) if the request is from a physician: (i) a completed application that includes professional experience, education, licenses and certificates, specialty or specialties, research, honors, professional memberships, and three professional references; (ii) a copy of DS-2019 form "Certificate of Eligibility for Exchange Visitor (J-1) Status" and USCIS form I-94 for the physician and the physician's spouse and children; and (iii) the case number issued by the United States Department of State indicating payment of the federal fee required to apply for the visa waiver; (c) a copy of the complete contract between the Conrad 30 J-1 visa waiver physician and the health care facility; (d) any required processing fee; and (e) any other information requested and determined by the department to be reasonably necessary to determine whether it is in the public interest that a waiver of the two-year home residency requirement be granted.