IHS Loan Repayment Program Application Handbook LRP573 LRP
User Manual: LRP573
Open the PDF directly: View PDF 
.
Page Count: 48
| Download | |
| Open PDF In Browser | View PDF |
Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook How to Apply Apply Here for Financial Freedom This booklet describes the Indian Health Service (IHS) Loan Repayment Program (LRP) and explains the application process. Application forms are included. If any changes should occur in the LRP program before contracts become effective, prospective recipients will be provided with revisions to this booklet prior to the conclusion of any loan repayment agreements. Please write or call the LRP office if you have any questions about the program or the application process. The information in this handbook is subject to change without notice. Please refer to www.loanrepayment.ihs.gov for the most up-to-date information. Dear Colleague, Thank you for your interest in the Loan Repayment Program (LRP). A career with the Indian Health Service (IHS) is an opportunity for professional and personal fulfillment — a chance to experience the rewards of working with an appreciative, underserved population while living in some of the most beautiful areas of the country. The costs of a health professional education are high, but the LRP can give you the financial freedom to pursue the future you’ve envisioned for yourself: a career with purpose and a sense of mission, treating patients who truly need you, and doing it all with adventure in your life. It’s no wonder that health professionals consider the LRP to be one of the most significant benefits IHS offers. On behalf of the Indian Health Service, thank you for your interest in providing health care to American Indians and Alaska Natives. Robert E. Pittman, R.Ph., M.P.H. Rear Admiral, USPHS Assistant Surgeon General Director, Division of Health Professions Support Privacy Act Notice General This information is provided to you in accordance with the Privacy Act of 1974 (Public Law [P.L.] 93-579), as you are supplying us with information for inclusion in a system of records. Authority Section 108 of the Indian Health Care Improvement Act (P.L. 94-437), as amended by the Indian Health Care Amendments of 1992 (P.L. 102-573). Program Administration The LRP is administered at the IHS Office of Public Health Support, Division of Health Professions Support. The IHS is one of 11 agencies of the US Department of Health and Human Services (HHS). Purpose and Uses The purpose of the LRP is to obtain health professionals to meet the staffing needs of the IHS in Indian health programs. The information you supply will be used to evaluate your eligibility for participation in the LRP. Your application and related data are included in a file to be used within HHS for recordkeeping and recipient management while you are in the program. The information may also be disclosed in accordance with the Privacy Act and IHS Privacy Act Systems of Records Notice 09-17-0002; disclosures to the public as required by the Freedom of Information Act, to the Congress, the National Archives, the Bureau of Accounting Office; and pursuant to court order. Your name (if awarded), the professional school you attend or have attended, and the date of graduation may be made available to health professions associations and to groups who have responsibility for coordinating educational loan repayment funds paid to individuals from federal and other sources, and to individuals and organizations deemed qualified by the Secretary of the US Department of Health and Human Services to carry out such research. Effects of Nondisclosure Under the Debt Collection Act, you are required to disclose your Social Security number (SSN) if you are awarded loan repayment. If you do not disclose your SSN, your application will be considered incomplete. Discrimination Prohibited Title VI of the Civil Rights Act of 1964, as amended, provides that no person in the United States (US) shall, because of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. Section 504 of the Rehabilitation Act of 1973, as amended, provides that no otherwise qualified handicapped individual in the US shall, solely by reason of his/her handicap, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program or activity receiving federal financial assistance. Contents 1 The IHS Loan Repayment Program 13 How to Apply 3 Are You Eligible? � 15 About LRP Application Forms 3 What Is an Indian Health Program? � 15 Application and Award Deadlines 3 How Are Recipients Selected? � 15 How to Reapply If You Are Not Selected 3 Award Distribution � 15 How to Complete the Application 5 Qualifying Loans and LRP Payments 7 Qualifying Loans 7 Verification of Total Debt From Qualified Loans 7 Payments 7 LRP Payment Examples 8 Delinquency on the Repayment of Any Federal Debt 8 Loans Not Eligible for Repayment 9 IHS Loan Repayment Service Obligation 11 Service � 11 Being Matched to a Site � 11 Employment Options � 15 Using the Checklist 16 Section 1: How to Complete the General Applicant Information Section 17 Section 2: How to Complete the Educational and Professional Background Section 18 Section 3: How to Complete the Financial Information Section 18 Section 4: A Review of the Comparison of Benefits Between Commissioned Corps and Civil Service (Including Affidavit) 18 Section 5: About the Sample Contract 19 LRP Application Forms 21 Application Checklist 22 Section 1: General Applicant Information 24 Section 2: Educational and Professional Background 26 Section 3: Financial Information 27 Section 4: Comparison of Benefits Between Commissioned Corps and Civil Service (Including Affidavit) 30 Section 5: Sample LRP Contract 35 Recruiter Information 37 Recruiter Offices � 38 IHS Discipline Chiefs � The IHS Loan Repayment Program Apply Here for Financial Freedom The IHS Loan Repayment Program Are You Eligible? All health professions are eligible to apply to the LRP. However, the professions that are actually funded change each year depending on Indian health program staffing needs. Please refer to www.loanrepayment.ihs.gov for the current year’s priority list. Applicants for the LRP must be health or allied health professionals who: • Are US citizens • Are committed to practice at an IHS or other Indian health program priority site � • Can begin service on or before September 30 for two continuous years of full-time clinical practice • Have a degree in a health profession* • Have a valid state license to practice in a health profession * Health professions eligible to apply: allopathic medicine and osteopathic medicine (various specialties as needed), podiatric medicine, physician assistant, nursing, public health nursing, dentistry, optometry, pharmacy, psychology, social work, environmental health, engineering, an allied health profession, or other health professions as determined by need. What Is an Indian Health Program? For LRP purposes, the term “Indian health program” is defined in the Indian Health Care Improvement Act (IHCIA; P.L. 94-437), as any health program or facility funded in whole or in part by IHS for the benefit of American Indians and Alaska Natives. These health programs or facilities must be administered directly by IHS, by any Indian Tribe or any Tribal or Indian organization contracted under The Indian Self-Determination Act, the Buy Indian Act, or by an Urban Indian organization pursuant to Title V of the IHCIA. How Are Recipients Selected? IHS has created a ranking system to distribute LRP awards with the utmost fairness. As the goal of the program is to fill staff vacancies in Indian health programs, the ranking system gives highest consideration to program staffing needs and shortages of specific health profession disciplines. Once the need is assessed, each site is ranked accordingly. Please refer to www.loanrepayment.ihs.gov for the latest priority list. Consistent with this priority, considerations in ranking applicants include: • American Indian/Alaska Native — IHS gives priority to applications made by American Indians and Alaska Natives and to individuals recruited through the efforts of Indian Tribes and Tribal or Indian organizations. • Current Service — Current LRP recipients requesting contract extensions are given priority over new awards. When all other factors are equal between applicants, additional equal-weight factors are applied. Applicants who meet more of the following factors than other applicants will be selected: • Current employment in an IHS, Tribal or Urban program. • Date of availability for service (first come, first served). • Date the application was received by the LRP. • Previous IHS Scholarship Program recipient. Applicants will be accepted into the LRP according to the above priorities as long as funds remain available during the fiscal year. Award Distribution Each year, funds appropriated for the LRP are distributed among the health professions depending on health program staffing needs. 3 Qualifying Loans and LRP Payments Apply Here for Financial Freedom Qualifying Loans and LRP Payments Please refer to the Federal Register notice for the current fiscal year for any updates or changes to the benefits of the program. Qualifying Loans The LRP repays qualifying health professions education loans as follows: • Qualifying loans are limited to government (federal, state, local) and commercial loans used to pay for health professions schools. • The LRP pays directly to the recipient the principal, interest, and related expenses (including tuition, fees, books, lab expenses and reasonable living expenses) incurred for qualifying health professions educational loans. • Up to $20,000 per year in loan repayment can be awarded � to recipients (in addition to their salary) who sign a contract � agreeing to a two-year service obligation. � • Twenty percent of the federal income tax liability on the LRP award as well as the recipient’s portion of the related FICA obligation are included in the award, with payment made directly to the Internal Revenue Service. • For consolidated loans (health professions education loans combined with commercial or other education loans), only the health professions education portion can be eligible under the LRP. Applicants must provide copies of final statements from the original lending institution at the time of the loan consolidation to determine the portion eligible for repayment. Documentation is required for all loans. However, verification of the purposes for which the loan was obtained is required for some loans. A number of federal program loans don’t require additional lender verification since they already meet statutory requirements. These include: • Health Education Assistance Loan (HEAL) Program • Guaranteed Student Loan (GSL) Program • Perkins Loan, formerly National Direct Student Loan (NDSL) Program � • Health Professions Student Loan (HPSL) Program • Supplemental Loans for Students (SLS) • Parent Loans for Undergraduate Students (PLUS) Loans All other loans require lender verification, including loans from undergraduate and graduate health professions schools. Verification of Total Debt From Qualified Loans When you are selected for participation in the LRP, copies of your financial information (Section 3 of the application) are used to verify total debt from your qualified education loans. Loan repayments will begin once the contract has been signed by you and by the Secretary of HHS or the Secretary’s IHS delegate, as provided in Section D of the LRP contract. Payments LRP payments are made to recipients in addition to the salary they receive for their employment. Letters of acceptance are sent on the last day of each month. If you are already employed by IHS or another Indian health program, LRP payments will begin within 120 days from the date the Secretary’s delegate signs the contract. For new LRP recipients who are not currently serving at an Indian health system facility, your payments begin 120 days from your entry-on-duty date or the start of your LRP contract date, whichever is later. LRP Payment Examples The following charts are examples of LRP payments for three different qualifying loan scenarios. Each example shows how annual payments are made. Recipient with a two-year service contract and $90,000 in qualifying education loans. LRP Award (per year) Amount Recipient Receives Amount Additional Withheld by IHS Payments for Recipient’s Made by IHS Portion of FIcA Total Payments Made by IHS $20,000 $18,164 $1,836 $25,836 1. $4,000 Income tax liability on the part of the recipient 2. $1,836 Employer’s portion of FIcA Recipient with a two-year service contract and $30,000 in qualifying education loans. If the recipient’s total loan amount can be paid within the two-year service obligation or is less than $40,000, the amount will be divided in half and awarded over two years. LRP Award (per year) Amount Recipient Receives Amount Additional Withheld by IHS Payments for Recipient’s Made by IHS Portion of FIcA Total Payments Made by IHS $15,000 $13,623 $1,377 $19,377 1. $3,000 Income tax liability on the part of the recipient 2. $1,377 Employer’s portion of FIcA 7 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook Recipient with a consolidated education loan. Loans Not Eligible for Repayment In this example, a recipient has obtained a professional degree in nursing and nutrition and comes to work at IHS as a registered nurse. Only the loans obtained in pursuit of the nursing education ($36,000) are eligible for repayment, while those obtained for the nutrition training are not. Any debts consisting of a service obligation must be satisfied prior to applying to the LRP. Any debts due to defaulted service obligations incurred under federal or state programs are not eligible for repayment under the LRP. Examples of these types of debts include, but are not necessarily limited to, the following: LRP Award (per year) $18,000 Amount Recipient Receives $16,348 Amount Additional Withheld by IHS Payments for Recipient’s Made by IHS Portion of FIcA Total Payments Made by IHS $1,652 $23,252 1. $3,600 Income tax liability on the part of the recipient 2. $1,652 Employer’s portion of FIcA Delinquency on the Repayment of Any Federal Debt If you are delinquent on the repayment of any federal debt, you must provide with your LRP application documentation from your lender that you have negotiated a repayment schedule or that your federal debt is paid in full. If this has not occurred, the LRP will not award a loan. If you have been awarded a loan and it is later discovered that you do have delinquent debt, your LRP payments could be garnished to satisfy delinquent debt unless you negotiate a repayment schedule. Examples of federal debt include: • � Delinquent federal income taxes • � Audit allowances • � Federally guaranteed (or insured) loans • � Federal-direct loans • � Other miscellaneous federal administrative debts 8 • The Physicians Shortage Area Scholarship Program • The Public Health Service and National Health Service Corps � Scholarship Program � • The IHS Health Professions Scholarship Program (P.L. 94-437, Section 104) • Armed Forces (Air Force, Army, Marines or Navy) Health Professions Scholarship Programs � • Any loan that requires a service obligation Also ineligible for repayment are: • Any credit card debt • Loans from other than approved government and commercial sources (e.g., loans obtained from private organizations, friends or relatives) • Loans or portions of loans obtained in pursuit of a different health profession from the one in which you are hired for the program. For example, if you obtain a professional degree in nutrition and nursing and come to work at IHS as a registered nurse, only the loans obtained in pursuit of the nursing education are eligible for repayment, while those obtained for the nutrition training are not. IHS Loan Repayment Service Obligation Apply Here for Financial Freedom IHS Loan Repayment Service Obligation Employment Options Service The LRP service obligation can be fulfilled through employment for the service period under any of several personnel systems. LRP recipients can choose from the following employment options to fulfill their service obligation: LRP recipients must serve their two-year contracted period in an IHS-approved priority site. IHS annually ranks all Indian health program sites in order of priority by position, with priority given to sites with the greatest vacancy rates and need. Please refer to www.loanrepayment.ihs.gov for the most recent priority listing. Being Matched to a Site Your selection for participation in the LRP is contingent on your having received an offer of full-time employment at an approved LRP site and agreed to begin service there before the end of the fiscal year (September 30). Your discipline-specific IHS Public Health Professions (PHP) recruiter will work with you to explore employment opportunities at IHS priority sites. To find your discipline-specific IHS recruiter, go to www.careers.ihs.gov and click Contact Us. • US Public Health Service Commissioned Corps — Commissioned officer with a salaried appointment. • Federal Civil Service — General Schedule (GS) employee. • Tribal Hire — Employee of a Tribal program conducted under � an Indian Self-Determination and Education Assistance Act � (P.L. 93-638) contract. • Urban Indian Program Employee — In a program assisted under Title V of the Indian Health Care Improvement Act (P.L. 94-437). • Buy Indian Contract Employee. Section 4 of this booklet contains full information on the Commissioned Corps and the federal Civil Service personnel systems, as required by law, so you can make an informed decision as to which service (if applicable) you would prefer if accepted into the program. An affidavit is included for you to sign, stating that you’ve been provided with and have read this information on the two personnel systems used by IHS, and that you understand the differences between the two. You must maintain a satisfactory level of employee performance at your approved site. Failure to meet these standards can result in termination of employment and therefore cause a breach of your LRP contract. 11 How to Apply Apply Here for Financial Freedom How to Apply About LRP Application Forms This booklet contains a complete set of LRP application forms. If you need additional forms or booklets, or have any questions, please contact the program at: Indian Health Service Loan Repayment Program 801 Thompson Ave., Suite 120 Rockville, MD 20852 How to Complete the Application This section takes you step by step through the LRP application. When you are finished, please review your application carefully before submitting. The checklist provided will assist you in preparing your application, and you should submit it along with your application. LRP applications must be complete and include all required support documentation. Incomplete applications are not eligible for consideration. The application is composed of five sections: Section 1: General Applicant Information Phone: (301) 443-3396 Fax: (301) 443-4815 Section 2: Educational and Professional Background www.loanrepayment.ihs.gov Section 4: Comparison of Benefits Between Commissioned Corps and Civil Service (Including Affidavit) 8:00 a.m.– 5:00 p.m. (EST), Monday through Friday (except federal holidays) Section 3: Financial Information Section 5: Sample LRP Contract (an official contract will be sent to you if you’re chosen for an award) Application and Award Deadlines Applications are accepted all year, but are processed for consideration from January through September 30 each award year, or until all funds are exhausted. The application deadline is the Friday of the second full week of each month. Successful applicants must begin their service period no later than September 30 of the fiscal year in which they were accepted into the LRP. How to Reapply If You Are Not Selected You will be notified by mail by October 31 if you are not selected for an LRP award. If you wish to reapply in the next LRP award cycle, you are required to notify LRP in writing. Your application will be kept on file and considered for all funding cycles. Please pay special attention to the Section 3 forms, which request details of all qualified loans you want considered for repayment. If you have more than one loan, complete a separate form for each individual loan. Make copies of a blank form if you need more forms than are provided. It is important that you submit all of these forms along with your application, as no additional forms will be accepted once an award is approved. Complete all sections of the application and review the information carefully before submitting. Mail the original forms, including the completed checklist, and any required documentation to: Indian Health Service Division of Health Professions Support Loan Repayment Program 801 Thompson Ave., Suite 120 Rockville, MD 20852 Please retain a copy of the entire application for your personal records. You will be notified by letter if you are approved for participation in the LRP, and an official contract will be sent to you. Using the Checklist The checklist is included to assist you in preparing your application and to ensure that it is complete. Check off each item as you complete it and gather the documentation required. Return the completed checklist along with your completed application. 15 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook Section 1: How to Complete the General Applicant Information Section The first section of the application covers general applicant information, including personal data, education information and details of existing service obligations. Line 1 — Name Provide your full legal name — last name first, then first name and, if applicable, middle name. Line 2 — Social Security Number (SSN) Enter your SSN on line 2. If you don’t provide it on your application and you are later selected for an LRP award, you will be required at that time to provide your SSN for purposes of payroll and payment to you of LRP benefits. This is a condition of your award. Lines 3 and 4 — Home Address, Home Telephone and Email Provide your full address, including apartment number if applicable, on line 3. Enter your home phone number, including area code, and your primary email address on line 4. Lines 5 and 6 — Work/School Address and Telephone/Email Provide your address at work or school, if applicable, on line 5. Be sure to include any apartment, room or mail stop numbers. On line 6, enter your work or school phone number, and your work/school email address if you have one and it’s different from your primary email address. If you do not have a work or school address, skip line 5 and 6 and go to line 7. Line 7 — Date of Birth • Standard Form 50B (SF-50B), also known as SF-50, is the Notification of Personnel Action. If you have ever been employed with the federal government, this form documents your service. Line 8b — If you are not employed with IHS and have checked NO, this line determines if you are employed in a program conducted or assisted under certain federal laws and acts. Contact your human resources department for assistance in determining the status of your program. • Check the first choice if you are employed in a program conducted under a contract entered into under the Indian Self-Determination and Education Assistance Act (P.L. 93-638 as amended). • Check the second choice if you are employed in a program assisted under Title V of the IHCIA (25 U.S.C. 1601). • Check the third choice if you are employed with a Buy Indian Act Organization (25 U.S.C. 47). If none of these choices describes your employment, skip this line and go on to line 9. Line 9 — American Indian/Alaska Native IHS gives priority to applications made by American Indians and Alaska Natives who are members of a federally recognized Tribe. Submit a copy of an approved Form BIA-4432, Verification of Indian Preference for Employment in the Bureau of Indian Affairs and the Indian Health Service with your application. You must use Form BIA-4432 as follows: American Indian: Category A — Members of federally recognized Tribes, bands or communities Alaska Native: Category D — Alaska Native Provide your date of birth here (mm/dd/yyyy). Line 8 — Employment at IHS Line 10 — IHS Health Professions (Section 104) Scholarship Recipient If you are currently employed with IHS, check the YES box and go to line 8a. If you are not currently employed with IHS, check the NO box and go to line 8b. IHS gives priority to applications made by former IHS Health Professions (Section 104) Scholarship recipients. Please submit a copy of your completion letter with your application. Line 8a — If you are employed with IHS and checked YES, this line requests details of your IHS employment. Check the appropriate box if you are in the USPHS Commissioned Corps or a federal Civil Service employee. Provide your entry date (the date you started work with IHS) and the site or location where you are employed. If you’re currently employed with IHS, provide employment verification documentation, as applicable: • IHS employment documentation (a letter from your employer stating dates of employment, full- or part-time status, job title, site name and entry-on-duty date) • Tribal employment documentation (a letter on Tribal letterhead stating dates of employment, full- or part-time status, job title, site name and hire date) • Commissioned Corps orders 16 Line 11 — Existing Service Obligation This line requests information on any existing service obligations you might have. A service obligation is defined as required employment for a period of time. If you have an existing service obligation as defined here, check YES and go to line 11a. If you do not have an existing service obligation, check NO and go to line 12. Line 11a — If you checked YES, provide details of your existing service obligation, including the program name and address, the name and telephone number of a contact person and the terms of your obligation. You are asked if you are in default of the obligation — check the appropriate YES or NO box. Finally, enter the date you will complete your existing service obligation. Apply Here for Financial Freedom Line 12 — Availability Date Line 4 — Practice Experience On this line, enter the date you will be available to begin work under the LRP. You must begin your service period no later than September 30 of the fiscal year in which you’re accepted into the LRP. Provide the details of your professional practice experience for the past five years. If this does not apply to you, write “NA” on the line and go to line 5. Section 2: How to Complete the Educational and Professional Background Section This section is to be completed by graduates only and details your educational and practice experience, if applicable. Information covered includes training and graduate programs, practice experience and licensing. If any line does not apply to you, write “NA” (for “not applicable”) on that line and go on to the next line. Line 1 — Professional School Provide the name of the professional school from which you graduated and the school’s full address. Enter the year you graduated or will graduate, and the degree you obtained. Line 2 — Residency/Graduate Program Information If you have completed a residency or graduate program, check the YES box and go to line 2a. If you have not completed a residency or graduate program, check the NO box and go to line 3. Line 2a — This line requests specific information about your residency or graduate program. Provide the year you completed or will complete your residency, school or graduate program, the name of the residency, school or graduate program, the address, and the residency/program director’s name and phone number. Line 2b — For physicians only, enter your specialty. Check the appropriate box if you are board certified or board eligible. If you are board certified, enter the year you will be re-certified. List your sub-specialty if you have one. Line 3 — Professional Training Locations This line requests information about your professional training locations. List each one separately. Provide program name and address, and the name and telephone number for the program director. If this does not apply to you, write “NA” on the line and go to line 4. As you describe your practice experience, include the following information: • Location(s) where you’ve practiced • The nature of the population served • Number of specialties in the practice • Any hospital affiliations • Allocation of clinical practice time to these specialties: � FP/GP, INT, OB/GYN, PED, PSYCH, ER � If you need more space to provide full information for line 4, please use a continuation sheet. At the top of the page, write Section 2, Line 4, Practice Experience, Continued, along with your name and SSN. Attach the sheet to your application. Line 5 — Last Work Site (If IHS, Tribal or Urban) For the last site where you worked, provide your job title, the name of the site director or other official, the site address and telephone number of the director or official. If this does not apply to you, write “NA” on the line and go to line 7. Line 6 — Practice Time Allocation On this line, enter the current percent of your practice time that is office-based and hospital/clinic-based and/or spent in administration and teaching. If this does not apply to you, write “NA” on the line and go to line 7. Line 7 — Professional References Information Provide a minimum of three professional references, including name, position or title, address and telephone number. This information will be kept confidential. Line 8 — Certification by Applicant This line asks you to sign to certify the accuracy of the information you are providing in Section 2 of the application. Sign your full name in ink and enter the date and your SSN. 17 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook Section 3: How to Complete the Financial Information Section This section requests details of qualified loans you want considered for the LRP. If you have more than one qualified loan, complete Section 3 forms for each individual loan. Submit copies of loan and payment documentation (current statements) that have the following identifying information: SSN, name and address. Line 1 — Lending Institution/Program Section 4: A Review of the Comparison of Benefits Between Commissioned Corps and Civil Service (Including Affidavit) In accordance with P.L. 100-713, Section 108(c)(1), which requires that the Indian Health Service (IHS) provide information on both the Commissioned Corps and Civil Service personnel systems, we ask that you read the attached information. The information will assist you in making an informed decision as you consider employment with IHS. Provide the name and address of the lending institution or the federal or state program from which you have obtained the loan that you wish to be considered for repayment. After you have reviewed the personnel systems information, please sign, date and return the affidavit as part of your completed application. Line 2 — Date of Loan Section 5: About the Sample Contract Enter the date the loan was originated (mm/dd/yyyy). This section is a sample LRP Contract. You will receive an official copy to sign and return if you are selected for an award. When you sign the contract, you will be agreeing to a service obligation to provide full-time clinical service in an Indian health program for two years for new recipients, or one year for extensions. Please read the sample contract thoroughly so that you fully understand all provisions. If you have any questions regarding the contract, call the LRP office at (301) 443-3396. Line 3 — Original Loan Amount Enter the original amount of your loan. This is not the current balance (see line 4). Line 4 — Current Loan Balance Enter the current balance of your loan and the date of the balance. Line 5 — Payment Amount Enter the amount of your regular loan payment. Line 6 — Deferment of Loan If your loan is in deferment, check the YES box and enter the date the deferment ends. Line 7 — Loan Annual Percentage Rate (APR) Enter the annual percentage rate (APR) of your loan. Consolidation of Undergraduate and Graduate Educational Loans The LRP pays for education costs for only one health professions degree. If you have consolidated your graduate and undergraduate loans into one loan, LRP will make a determination of what portion of the consolidated loan will be repaid for successful applicants. Attach copies of the loan documents for the health professions loans that were consolidated into the new loan, along with a copy of your current statement that includes your SSN, your name and address. Line 8 — Certification by Applicant This line asks you to sign to certify the accuracy of the information you are providing in Section 3 of the application. Sign your full name in ink and enter the date. Line 9 — Lender Verification This line asks your lender to sign to certify the accuracy of the information provided in Section 3 of the application. 18 LRP Application Forms Apply Here for Financial Freedom Application Checklist The following items make up your complete LRP application. Please refer to the booklet for a detailed description of each section and how to fill out the requested information. Section 1: General Applicant Information Section 2: Educational and Professional Background for graduates only Section 3: Financial Information, to include lender documentation Section 4: Signed Affidavit — Attesting that you’ve read the comparison of IHS personnel systems Section 5: Signed Sample Contract Required Documentation That Must Accompany Your Application: License to Practice — Provide a copy of full and unrestricted state license � Employment Verification — Provide IHS or Tribal employment verification, Commissioned Corps Orders, SF-50B � Special Circumstances: American Indian or Alaska Native — Form BIA-4432 (Verification of Indian Preference for Employment in the Bureau of Indian Affairs and the Indian Health Service) IHS Health Professions (Section 104) Scholarship Recipient — Completion Letter, if applicable, P.L. 94-437 21 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook FORM APPROVED OMB Approval No. 0917-0014 Exp. Date 02/29/2012 department of Health and Human Services Public Health Service Indian Health Service Loan Repayment Program Application for the Indian Health Service Loan Repayment Program Section 1: General Applicant Information Estimated Average Burden Time to Complete the Application Form: Public reporting burden for this collection of information is estimated to vary from 60 to 120 minutes per response with an average of 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, Reports Clearance Officer, Attn: PRA (0917-0014), 12300 Twinbrook Parkway, Suite 450, Rockville, MD 20852. Do not mail completed forms to the above address. Mail completed applications to: Loan Repayment Program, 801 Thompson Ave., Suite 120, Rockville, MD 20852 (Only complete applications will be considered.) PERSONAL INFORMATION 1. Name _____________________________________________________________________________________________________ Last First Middle 2. Social Security Number_______________________________________________________________________________________ (Applicants may choose to provide their SSN on a voluntary basis. Should you be awarded an LRP award, you will be required at that time to provide your SSN for purposes of payroll and payment to you of LRP benefits as a condition of your award.) 3. Home Address ______________________________________________________________________________________________ Number Street Apt. # _____________________________________________________________________________________________________________ City State ZIP Code 4. Home Telephone ____________________________________ Email __________________________________________________ 5. Work/School Address ________________________________________________________________________________________ Number Street Apt. or Room # _____________________________________________________________________________________________________________ City State ZIP Code 6. Work/School Telephone ______________________________ Email (if applicable) ________________________________________ 7. Date of Birth (mm/dd/yyyy) _____________________________________________________________________________________ 22 Apply Here for Financial Freedom Section 1 (continued) 8. Are you currently employed with IHS? Yes No 8a. If YES: Please submit employment verification with application Current IHS employment is with Commissioned Corps Civil Service � Entry Date _________________________________________ Site/Location ___________________________________________ � 8b. If NO: Is your current employment with: (If you check any, you must submit employment verification with your application) A program conducted under a contract entered into under the Indian Self-Determination Act A program assisted under Title V of the IHCIA � A Buy Indian Act organization 9. Are you an American Indian or Alaska Native? Yes No (If YES, please submit Form BIA-4432 with your application) 10. Have you ever received an IHS Health Professions (Section 104) Scholarship? Yes No (If YES, please submit a copy of your completion letter with your application) 11. Do you have an existing service obligation? Yes No (For the definition of existing service obligations, see the LRP handbook “How to Apply for your Financial Freedom,” Section 1, page 16, instructions for Line 11.) 11a. If YES: Name of Program___________________________________________________________________________________________ Address of Program _________________________________________________________________________________________ Contact Person ____________________________________________ Phone __________________________________________ Terms of the obligation ______________________________________________________________________________________ Are you in default of the obligation? Yes No � Date of Completion__________________________________________________________________________________________ � 12. Date you will be available to begin practice under the LRP ________________________________________________________ 23 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook FORM APPROVED OMB Approval No. 0917-0014 Exp. Date 02/29/2012 Section 2: Educational and Professional Background (Educational and Professional Background for Graduates Only) 1. Name of Professional School __________________________________________________________________________________ School Address _______________________________________________________________________________________________ Number Street Apt. or Room # Graduate year and degree obtained_______________________________________________________________________________ 2. Have you completed a residency or graduate program? (MD, DO, DDS, PedNP, PA, etc.) Yes No 2a. Year residency or program was/will be completed_____________________________________________________________ Residency or Program Name __________________________________________________________________________________ Address___________________________________________________________________________________________________ Director of Residency/Program ________________________________________________________________________________ Name Phone 2b. Specialty (for physicians only) _______________________________________________________________________________ Board Certified Board Eligible � Year re-certified (if applicable)____________________ � Sub-specialty (if applicable) ______________________ � 3. If applicable, please list all professional training location(s) separately. a. Program Name_____________________________________________________________________________________________ Address ____________________________________________________________________________________________________ Program Director’s Name______________________________________________ Phone ___________________________________ b. Program Name_____________________________________________________________________________________________ Address ____________________________________________________________________________________________________ Program Director’s Name______________________________________________ Phone ___________________________________ c. Program Name _____________________________________________________________________________________________ Address ____________________________________________________________________________________________________ Program Director’s Name______________________________________________ Phone ___________________________________ 4. If applicable, describe your practice experience over the last five years. (Include location, nature of population served, number of specialties in the practice, hospital affiliations and allocation of clinical practice time to FP/GP, INT, OB/GYN, PED, PSYCH, ER. If you need more space, please use continuation sheet, type your name and SSN at the top of each page, and attach to your application.) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 24 Apply Here for Financial Freedom Section 2 (continued) 5. For the last site at which you worked: Name of Site Director or Official__________________________________________________________________________________ Your Job Title ________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ Phone______________________________________________________________________________________________________ 6. Practice Time Allocation: Office-based ________ Hospital/clinic-based _________ Administration ________ Teaching _______ 7. Professional References (confidential) Name Position or Title Address Phone Number 8. Certification by Applicant I certify that the information given in this application is accurate to the best of my knowledge and belief. I understand that it may be investigated and that any willfully false representation is sufficient cause for rejection of this application; and if awarded a loan repayment, that I am liable for repayment of all awarded funds and, further, that any false statement herein may be punished as a felony under US Code Title 18 Section 1001. _____________________________________________________________________________________________________________ Signature (Sign Your Full Name in Ink) Date SSN ______________________________________ 25 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook FORM APPROVED OMB Approval No. 0917-0014 Exp. Date 02/29/2012 Section 3: Financial Information Important: As an applicant, you are applying for loan repayment with the Department of Health and Human Services (HHS), Indian Health Service (IHS) Loan Repayment Program (LRP) provided for in P.L. 100-713. It is important to submit your financial information promptly to the LRP. Please complete the following information for each educational loan you submit to the LRP. Include loan and payment documentation with your application. 1. Name of lending institution and/or federal or state program _______________________________________________________ Address ____________________________________________________________________________________________________ 2. Date of Loan (mm/dd/yyyy) ________________________________________ 3. Original Amount of Loan $ _______________________________________ 4. Current Balance $ ________________ Date of Balance _______________ 5. Payment Amount $ _____________________________________________ 6. Is loan in deferment? Yes No � IF YES, date deferment ends _______________________________________ � 7. Annual percentage rate (APR) of loan______% For consolidation of undergraduate and graduate educational loans If you have consolidated your loans for undergraduate and graduate costs, you must attach copies of the loan documents for health professions education costs that were consolidated into a new loan. The LRP pays for education costs for only one health professions degree, and a determination will be made of the proportion of the consolidated loan that will be paid for successful applicants. Warning: Any person who knowingly makes a false statement or misrepresentation in this loan repayment transaction, bribes or attempts to bribe a federal official, fraudulently obtains repayment for a loan under this statute, or commits any other illegal action in connection with this transaction is subject to a fine or imprisonment under federal statute. I have read this statement and understand its contents. _____________________________________________________________________________________________________________ Signature Title Date 8. Certification by Applicant I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Secretary of HHS for repayment of the educational loans I have listed in Section 3. I attest that my health educational loans were incurred solely for the purpose of paying for the costs of my education and reasonable living expenses while attending college/university, and for obtaining a degree in medicine, dentistry, nursing, optometry, pharmacy, podiatry, mental health or allied health profession. _____________________________________________________________________________________________________________ Signature (Sign Your Full Name in Ink) Date 9. Lender Verification I understand to the best of my knowledge that the loan identified above is a legally enforceable commercial, state or government educational loan and its purpose was to pay for the borrower’s cost of completing a degree in medicine, dentistry, nursing, optometry, pharmacy, podiatry, mental health or allied health profession. _____________________________________________________________________________________________________________ Signature 26 Title Date Apply Here for Financial Freedom FORM APPROVED OMB Approval No. 0917-0014 Exp. Date 02/29/2012 Section 4: Comparison of Benefits Between Commissioned Corps and Civil Service (Including Affidavit) We ask that you read the following information on the two personnel systems used by the IHS: The Commissioned Corps and the Civil Service. IHS is required to provide you with this information, in accordance with P.L. 100-713, Section 108(c)(1), to assist you in making an informed decision as you consider employment with the IHS. After you have reviewed the personnel systems information, please sign, date and return the affidavit to the LRP as part of your completed application. BENEFITS A. Moving Expenses B. Vacation Allowances � COMMISSIONED CORPS CIVIL SERVICE Call to active duty: Call to active duty: Pays to move officer’s family and household goods, within certain weight limits, from current residence to duty station. Pays to move physician’s family and household goods, within certain weight limits, from current residence to duty station. Other professions must consult human resources office in the IHS area where you are hired. On duty: On duty: Pays to move officer’s family and household goods, within certain weight limits, from duty station to duty station. Pays to move an employee’s family and household goods, within certain weight limits, from duty station to duty station. On separation or retirement: On separation or retirement: Pays to move officer’s family and household goods, within certain weight limits, from duty station to home of record or the place from which called to duty, whichever is farther, or equivalent distance. � Provides no assistance in moving from final duty station to next place of residence. � An officer earns 30 days of annual leave per year (two and a half days per month) from the time he/she enters on duty. A total of 60 days may be carried from year to year and may be reimbursed on the officer’s separation or retirement. A civil servant earns 13 working days of annual leave per year (four hours per pay period, 26 pay periods per year for the first three years). From the fourth year through the 15th, he/ she earns six hours of annual leave per pay period (20 working days per year). From the beginning of the 16th year until retirement, eight hours of annual leave accrues per pay period (26 working days per year). A total of 30 days (240 hours) of annual leave may be carried over from year to year and will be reimbursed on separation or retirement. 27 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook Section 4 (continued) BENEFITS COMMISSIONED CORPS CIVIL SERVICE C. Sick Leave No formal rate of accrual. Sick leave may be granted when the officer is in need of medical services or is incapacitated for the performance of duties by sickness, injury, or pregnancy and confinement. The leave granting authority or other responsible official may require a medical certificate for every period of sick leave in excess of three days, or for a lesser period when determined to be necessary. Sick leave is accrued at the rate of four hours per pay period for the length of employment. There is no maximum carryover limit. D. Retirement � The Commissioned Corps retirement system is structured on the basis of a 30-year career. Pay increases based on length of service continue throughout an officer’s career. Retired pay is based on 30 years of service (75 percent of basic pay). With approval, an officer may retire after completing 20, but less than 30, years of active service. To be eligible for consideration for such retirement, the officer must have 20 years of creditable service. The Commissioned Corps retirement system is noncontributory. The Civil Service retirement system is a threetiered contributory comprehensive program allowing Civil Service employees to control a large portion of their retirement savings. The program consists of a base retirement annuity, Social Security benefits, and a government matching savings program which allows employees to invest the savings money in government securities, the bond market and/or the common stock market. E. Health Insurance Officer: US Public Health Service (PHS) officers are entitled to health care from any uniformed service medical treatment facility (MTF). Health care services may be supplemented by other resources in accordance with uniformed service policies and procedures. Choice of medical and dental plans range from traditional fee-for-service plans to prepaid HMOs. Employee payments and benefits vary with the plan chosen. Benefits are provided to employees and dependents on a costsharing basis. Dependents: Dependents are entitled to health care from an MTF on a space-available basis. TRICARE is the name for the Department of Defense triple option health care program. Dependents’ dental care can be provided by voluntary enrollment in the Active Duty Family Member Dental Plan. 28 Apply Here for Financial Freedom Section 4 (continued) BENEFITS COMMISSIONED CORPS CIVIL SERVICE F. Tax Benefits The basic allowance for quarters, variable housing allowance, and subsistence allowance are nontaxable. All other pay is taxable. All pay is taxable. G. Military Benefits Two years of active duty in the Commissioned Corps satisfies a person’s Selective Service obligation. Civil Service makes no provision here. H. Air Transportation Officers are eligible to fly on military aircraft within the US and overseas (foreign travel) on a “space-available” basis. Their families may fly overseas only, on the same basis. Civil Service makes no provision here. I. Personal Amenities Officers and dependents may use the commissary, post exchange, transient officer quarters and other facilities at military bases. Civil Service makes no provision here. J. Medical License Must have a full and unrestricted license in a state. Must have a full and unrestricted license in a state. K. Impact of Loan Repayment Program on Salary Participation in the LRP has no impact on pay. Participation in the LRP will reduce or eliminate the Physicians Comparability Allowance. Physicians should discuss this with their area recruiters.* * If you are currently receiving a Physician’s Comparability Allowance (PCA) bonus, your participation in the LRP may reduce or eliminate your eligibility to receive the PCA bonus. The PCA bonus is only available to Civil Service employees. For further information, please contact the LRP office. I certify that I have read the information regarding the Civil Service and Commissioned Corps personnel systems and understand that I must select one to be employed by the Indian Health Service. _____________________________________________________________________________________________________________ Name (Please Print) Signature Date 29 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook FORM APPROVED OMB Approval No. 0917-0014 Exp. Date 02/29/2012 Section 5: Sample LRP Contract This section is a sample LRP contract. You will receive an official copy to sign and return if you are selected for an award. When you sign the contract, you will be agreeing to a service obligation to provide full-time clinical service in an Indian health program for one year for each year of loan repayment. Please read this sample contract thoroughly so that you fully understand all provisions. If you have any questions regarding the contract, call the LRP office at (301) 443-3396. Loan Repayment Program — Sample Contract Section 108 of the IHCIA (P.L. 94-437), as amended, authorizes the Secretary of Health and Human Services, acting through the Indian Health Service (IHS), to establish the Indian Health Service (IHS) Loan Repayment Program (LRP) under which federal, state, and commercial loans for physicians and other health professionals may be repaid at a rate not to exceed $20,000 per year. In return for such loan repayment, recipients must agree to provide full-time clinical service in an Indian health program for a period of obligated service equal to one year for each year of loan repayment. Section 108 requires recipients to submit with their applications a written contract to accept repayment of educational loans and to serve for the applicable period of obligated service in an Indian health program. The Secretary shall sign only those contracts submitted by recipients who are selected for the program. Section A — Obligations of the Secretary Subject to the availability of funds appropriated by Congress for the IHS and the LRP, the Secretary agrees to: 1. � Make payments to the recipient for each year of service of the lesser of up to $20,000 or the total amount of the recipient’s eligible health professions educational loans divided by the number of years of obligated service. Loans eligible for repayment consist of loan costs identified by the promissory note indicating the principal, interest, and related expenses on federal, state, and commercial loans received by the recipient for tuition expenses; all other reasonable educational expenses incurred by the recipient; and reasonable living expenses as determined by the Secretary. 2. �Accept the recipient into the IHS or place the recipient with a Tribe or Tribal or Indian organization provided that the recipient meets all appropriate employment qualifications. � 3. �Make loan repayments for each year of obligated service in which the recipient completes such year of obligated service. All contracts are for whole years (for example: two whole years and no fraction or part of a year). 4. Pay, on behalf of the recipient, an amount not less than 20 percent and not more than 39 percent of the recipient’s total amount of loan repayments to the Internal Revenue Service for all or part of the increased tax liability. 30 5. � Defer performance of a recipient’s period of obligated service if the recipient: � a. �Receives a degree from a school of medicine, osteopathy, dentistry, optometry, podiatry, pharmacy, nursing, psychology, public health, social work, or other health profession, and b. � Requests a deferment of this period to complete internship, residency, or other advanced clinical training. The period of deferment may not exceed: (1) three years for recipients receiving a degree from a school of medicine, osteopathy or dentistry (2) �one year for recipients receiving a degree from a school of optometry, podiatry, pharmacy, nursing, psychology, public health, social work, or other health profession The Secretary may, however, extend this period of deferment if the Secretary determines that the extension is consistent with the needs of the IHS. Section B — Obligation of the Recipient If selected, the recipient agrees: 1. To accept loan repayment provided by the Secretary under � Section A of this contract and to apply such payments only to outstanding eligible health professions educational loans. � 2. To serve in accordance with this Section for two years. *3. �Recipient’s health profession ____________________________ * Must be completed by recipient. 4. In the case of a recipient described in Section 108(b) (1)(A) � (B)(i)(ii), (i.e., In the final year of a course of study or in an approved graduate training program): � a. �To maintain enrollment in a course of study or training, to maintain an acceptable level of academic standing. � 5. To serve for a time period (hereinafter referred to as the “period � of obligated service”) equal to two years or such longer period � as the recipient may agree to serve in the full-time clinical practice of the recipient’s profession in an Indian health program � to which the recipient may be assigned by the Secretary. � 6. �To accept assignment, as determined by the Secretary, for the recipient’s full period of obligated service in a Loan Repayment Program priority site designated for the recipient’s � profession or specialty by the IHS. � 7. To have a current and unrestricted license or certificate, � as necessary for the recipient’s profession, to practice the recipient’s health profession in a state within the US prior to commencing obligated service, and maintain that license or � certificate throughout the period of obligated service. � Apply Here for Financial Freedom 8. To commence obligated service in accordance with this contract prior to September 30,____ , and continue uninterrupted service for the duration of the recipient’s service obligation period, except as provided in Section G of this contract or unless recipient’s service obligation is deferred by the Secretary pursuant to Section A(5) of this contract. 9. �To comply with the provisions of Title 42, Code of Federal Regulations, Part 36, Subpart J, when adopted. Should any � provision of Subpart J be inconsistent with this contract, the regulatory provision will be controlling. � 10. � Recipients serving a contract extension under Section E — Contract Extension have served at least a two-year “period of obligated service” prescribed in Section 108(f)(1)(B)(iii) of the IHCIA (P.L. 94-437) as amended by the Indian Health Care Amendments of 1992 (P.L. 102-573). 11. All LRP recipients must forward in writing any change of address, financial institution, or employment status within 30 days to the following address: Indian Health Service Loan Repayment Program 801 Thompson Ave., Suite 120 Rockville, MD 20852 12. Any recipient who is terminated or resigns from their place of Employment must submit in writing the reason for their nonemployment within 30 days, or their account will be placed into default and debt collection proceedings will be initiated. Section C — LRP Contract The effective date of the LRP contract is calculated from the date it is signed by the Secretary or his/her delegate, or the IHS Tribal, Tribal/Urban, or “Buy Indian” health center entry-on-duty date, whichever is more recent. If already on duty with the IHS or other Indian health program, calculate from the date of contract; if the contract is signed prior to reporting to duty, calculate from the entry-on-duty date. Section D — LRP Payments LRP payments will begin within 120 days from the date the LRP contract becomes effective (calculated from the date the LRP contract is signed by the Secretary or his/her delegate, or the IHS, Tribal/Urban organization, or “Buy Indian” health center entryon-duty date, whichever is more recent. If already on duty with the IHS or other Indian health program, calculate from the date of contract; if contract is signed prior to reporting to duty, calculate from the entry-on-duty date). Contract extensions will be paid 120 days from initial anniversary date. (See Section E.) Section E — Contract Extension 1. Recipients may, in accordance with procedures established by the Secretary, request an extension of this contract. 2. Subject to the availability of funds appropriated by the Congress of the United States for IHS and the LRP, the Secretary may approve requests for extension of this contract if: a. � The recipient remains eligible for participation in the LRP, and b. � The total period of obligated service does not exceed the number of years that it will take to repay the total amount of the individual’s outstanding eligible health professions educational loans up to $20,000 per year under the terms and conditions of this contract. Individuals extending a contract initially approved prior to FY 2000 are eligible to receive the total amount of the individual’s outstanding health professions educational loans up to $30,000 per year under the terms and conditions of this contract. 3. �Recipients will be allowed to submit additional Section III financial information not covered under their initial verification of debt, as long as the debt to be considered meets the provisions in the subject section entitled, “For Consolidation of Undergraduate and Graduate Educational Loans,” and complies with subsection (2)(b) of this section. Once the Secretary or his/her authorized representative approves a contract extension, the period of obligated service thereunder shall be calculated beginning the first day after which the recipient’s initial period of obligated service is completed, if completed the same fiscal year in which the contract extension is approved and if the recipient remains on duty after completion of his/her initial period of obligated service. However, when program funds are exhausted, the Secretary will not sign and approve contract extension requests, and no credit will be given for the time served after the completion of the initial obligated service. LRP recipients are therefore encouraged to make their contract extension requests as early as possible, preferably nine months prior to the completion of their initial period of obligated service. **4. To serve in accordance with Section E — Contract Extension for a period of 1 year. _______________ ** This provision applies only to those LRP recipients who have completed their two-year period of obligated service. Must be initialed by recipient if applying for a contract extension. 5. All requests for a contract extension must include a payment history from your lending institution(s) indicating that maximum payments from the LRP were applied to your eligible outstanding debt since your acceptance into the LRP. 31 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook Section F — Breach of Loan Repayment Contract, Damages 1. If a recipient who has entered into a written contract with the Secretary and who — a. Is enrolled in the final year of a course of study, and who — (1) fails to maintain an acceptable level of academic standing in the educational institution in which the recipient is enrolled (2) voluntarily terminates such enrollment (3) is dismissed from such educational institution before completion of such course of study (4) fails to apply loan repayments to his/her health professions educational loans 2. If, for any reason not specified in paragraph (1), a recipient � breaches his/her written contract by failing either to begin, or complete, the recipient’s period of obligated service in accordance with Section 108(f), the United States shall be entitled to recover from the recipient an amount to be � determined in accordance with the following formula: � A = 3Z[(t-s)/t] in which: a. “A” is the amount the United States is entitled to recover. b. “Z” is the sum of the amounts paid under this Section to, or on behalf of, the recipient and the interest on such amounts which would be payable if, at the time the amounts were paid, they were loans bearing interest at the maximum legal prevailing rate, as determined by the Treasurer of the United States. c. “t” is the total number of months in the recipient’s period of obligated service in accordance with Section 108(f). d. “s” is the number of months of such period served by such recipient in accordance with this section. 3. Any amount of damages which the United States is entitled to receive under this contract shall be subject to the United States within the one-year period beginning on the date of the breach or such longer period beginning on such date as shall be specified by the Secretary, and may include all collection costs including any litigation costs. Amounts not paid within the one-year period shall be subject to collection through deductions in Medicare payments pursuant to Section 1892 of the Social Security Act. 4. � Unsatisfactory performance by a recipient resulting in the termination of the recipient’s employment during the recipient’s period of obligated service shall be considered � a breach of this contract. � 32 Section G — Creditability of Graduate Training Toward Period of Obligated Service No credit of time for internship, residency, or other advanced � clinical training will be counted toward satisfying the period � of obligated service incurred under this contract. � Section H — Cancellation, Suspension, Waiver, and Release of Obligation 1. Any service or payment obligation incurred by the recipient under this contract will be cancelled upon the recipient’s death. 2. � The Secretary may waive or suspend, in whole or in part, the recipient’s service obligation incurred under this contract if compliance by the applicant is impossible or would involve extreme hardship to the individual and if enforcement of such obligation with respect to the recipient would be unconscionable. 3. � The Secretary may waive, in whole or in part, the rights of the United States to recover amounts under this Section in any case of extreme hardship, as determined by the Secretary. 4. Any obligation of a recipient under the Loan Repayment � Program for payment of damages may be released by a discharge in bankruptcy under Title 11 of the United States � Code only if such discharge is granted after the expiration of the five-year period beginning on the date that payment � of such damages is required and only if the bankruptcy � court finds that non-discharge of the obligation would be � unconscionable. � 5. All waiver requests to the LRP must be made in writing. � Any LRP waiver approval, denial, or decision will be made � to the recipient in writing within 30 days of the Waiver � Committee’s decision. � Apply Here for Financial Freedom Section I — Drug Free Workplace Certification By signing and submitting this contract, the Indian Health Service Loan Repayment Program recipient certifies, in accordance with 45 CFR Part 76, as a condition of the contract, he/she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance while conducting any activity under the contract. _____________________________________________________________________________________________________________ Recipient’s Name (Please Print or Type) Recipient’s Signature Date I understand that any financial obligation of the United States arising out of this contract and my obligation arising out of this contract are contingent upon funds being appropriated by Congress for the LRP. The Secretary or his/her authorized representative must sign this contract before it becomes effective. Further, I understand that any indebtedness I incur prior to both parties, the Secretary and myself, signing this contract is my responsibility. _____________________________________________________________________________________________________________ Recipient’s Name (Please Print or Type) Recipient’s Signature Date _____________________________________________________________________________________________________________ Secretary of Health and Human Service (or Delegate’s) Signature Date For Official Use Only Recipient’s account will be obligated for $________________ and will serve his/her ________ year obligation at the following site. _________________________________________________________________________________________________________________________________ Official _____________________________________________________ Date _________________________________________________________ Appropriation Number: ________________________________________ CAN _________________________________________________________ 33 Recruiter Information Apply Here for Financial Freedom Recruiter Offices Aberdeen Area IHS (Iowa, Nebraska, North Dakota, South Dakota) 115 4th Ave., SE � Aberdeen, SD 57401 � Phone: (605) 226-7532 � Fax: (605) 226-7321 � Alaska Area Native Health Services (Alaska) 4141 Ambassador Dr., Suite 300 � Anchorage, AK 99508 � Phone: (907) 729-1337, (907) 729-1332 or (800) 684-8361 � Fax: (907) 729-1335 � Albuquerque Area IHS (Colorado, New Mexico) 5300 Homestead Rd., NE � Albuquerque, NM 87110 � Phone: (505) 248-4418 � Fax: (505) 248-4938 � Bemidji Area IHS (Illinois, Indiana, Michigan, Minnesota, Wisconsin) 522 Minnesota Ave., NW, Room 119 � Bemidji, MN 56601 � Phone: (218) 444-0486 � Fax: (218) 444-0498 � Billings Area IHS (Montana, Wyoming) 2900 Fourth Ave., North � Billings, MT 59101 � Phone: (406) 247-7100 � Fax: (406) 247-7245 or (406) 247-7230 � California Area IHS (California, Hawaii) 650 Capitol Mall, Suite 7-100 � Sacramento, CA 95814 � Phone: (916) 930-3981 ext. 724 � Fax: (916) 930-3952 � Eastern United States IHS (Alabama, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia and District of Columbia) Nashville Area IHS � 711 Stewarts Ferry Pike � Nashville, TN 37214 � Phone: (615) 467-1628 � Fax: (615) 467-1501 � Navajo Area IHS (Arizona, New Mexico, Utah) PO Box 9020 � Window Rock, AZ 86515 � Phone: (800) 221-5646 � Fax: (928) 871-1383 � Oklahoma City Area IHS (Kansas, Missouri, Oklahoma) 5 Corporate Plaza � 3625 NW 56th St. � Oklahoma City, OK 73112 � Phone: (405) 951-6040 or (800) 722-3357 � Fax: (405) 951-3953 � Phoenix Area IHS (Arizona, Nevada, Utah) 2 Renaissance Square � 40 N. Central Ave. � Phoenix, AZ 85004 � Phone: (602) 364-5253 � Fax: (602) 364-5358 � Portland Area IHS (Idaho, Oregon, Washington) 1220 SW Third Ave., #476 � Portland, OR 97204 � Phone: (503) 326-3288 � Fax: (503) 326-2702 � Tucson Area IHS (Arizona, Texas) 7900 S. J Stock Rd. � Tucson, AZ 85746 � Phone: (520) 295-2440 � Fax: (520) 295-2434 � 37 Indian Health Service Loan Repayment Program APPLIcAtIon HAndbook IHS Discipline Chiefs The IHS Discipline Chief of your particular health discipline will work with you to explore employment opportunities at IHS priority sites. Please refer to the following listing of the Discipline Chiefs. Behavioral Health Indian Health Service, HQE � 801 Thompson Ave., Suite 300 � Rockville, MD 20852 � Phone: (301) 443-2038 � Dentistry Chief, Dental Program � 801 Thompson Ave., TMP 450 � Rockville, MD 20852 � Phone: (301) 443-0029 � www.dentist.ihs.gov � Dietetics/Public Health Nutrition Indian Health Service, HQE � 801 Thompson Ave., TMP 450 � Rockville, MD 20852 � Phone: (301) 443-0576 � Engineering Indian Health Service, HQE � Environmental Health and Engineering � 801 Thompson Ave., TMP 610 � Rockville, MD 20852 � Phone: (301) 443-1046 � Environmental Health/Sanitation Indian Health Service, HQE � 801 Thompson Ave., TMP 610 � Rockville, MD 20852 � Phone: (301) 443-1054 � 38 Medical Records Indian Health Service, PHX � 2 Renaissance Square � 40 N. Central Ave., Suite 606 � Phoenix, AZ 85004 � Phone: (602) 364-5162 � Medical Technology Clinical Applications Administrator – CRSU � Parker Indian Health Center � 12033 Agency Rd. � Parker, AZ 85344 � Phone: (928) 669-3226 � Nursing (Advanced Practice) Director, DNS � 801 Thompson Ave., TMP 450 � Rockville, MD 20852 � Phone: (301) 443-1840 � Nursing (ADN, BSN, MSN) Nursing � IHS Recruitment Branch � Indian Health Service � 801 Thompson Ave., Suite 300 � Rockville, MD 20852 � Phone: (301) 443-1840 � Optometry Chief, Optometry Program � Standing Rock Indian Hospital � 10 River Rd. � Ft. Yates, ND 58538 � Phone: (701) 854-8249 � Apply Here for Financial Freedom Pharmacy Pharmacy IHS Recruitment Branch Indian Health Service 801 Thompson Ave., Suite 300 Rockville, MD 20852 Phone: (301) 443-4330 Physician IHS Recruitment Branch Indian Health Service 801 Thompson Ave., TMP 450A Rockville, MD 20852 Phone: (301) 443-4242 Physician Assistant Physician Assistant Chief Clinical Consultant, IHS Cherokee Indian Hospital Caller Box C-268 Cherokee, NC 28719 Phone: (828) 497-9163, ext. 6499 Podiatry Phoenix Indian Medical Center 4242 North 16th St. Phoenix, AZ 85016 Phone: (602) 263-1673 Radiologic Technology/Ultrasonography Director, Medical Imaging Program 2 Renaissance Square 40 N. Central Ave., Suite 600 Phoenix, AZ 85004 Phone: (602) 364-5166 Rehabilitative Services Chief Clinical Consultant, Physical Rehabilitation Services Indian Health Service Whiteriver Service Unit Physical Therapy Department 200 Hospital Dr. Whiteriver, AZ 85941 Phone: (928) 338-3610 39 notES 40 41 � Apply Here for Financial Freedom Indian Health Service Division of Health Professions Support Loan Repayment Program 801 Thompson Ave., Suite 120 � Rockville, MD 20852 � Phone: (301) 443-3396 � Fax: (301) 443-4815 � www.loanrepayment.ihs.gov
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.7 Linearized : Yes Author : Indian Health Service Create Date : 2009:04:23 09:01:59-04:00 Keywords : Indian Health Service, Loan Repayment, IHS Loan Repayment, LRP, LRP Application Modify Date : 2009:08:24 12:49:52-05:00 Has XFA : Yes Language : EN-US Tagged PDF : Yes XMP Toolkit : Adobe XMP Core 4.2.1-c041 52.342996, 2008/05/07-20:48:00 Instance ID : uuid:f331bd1e-9fbf-4a75-8b9a-bf76f1c5764b Document ID : adobe:docid:indd:b7de567c-16fe-11de-964d-83160d0dab5f Rendition Class : proof:pdf Derived From Instance ID : b7de567b-16fe-11de-964d-83160d0dab5f Derived From Document ID : adobe:docid:indd:e2a994c1-10f8-11de-95e3-d1119d0e74fd Manifest Link Form : ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream, ReferenceStream Manifest Placed X Resolution : 72.00, 300.00, 300.00, 300.00, 300.00, 72.00, 240.00, 72.00, 72.00, 240.00, 72.00, 240.00, 72.00, 240.00, 72.00, 72.00, 72.00, 240.00, 72.00, 240.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 240.00, 72.00, 72.00, 72.00 Manifest Placed Y Resolution : 72.00, 300.00, 300.00, 300.00, 300.00, 72.00, 240.00, 72.00, 72.00, 240.00, 72.00, 240.00, 72.00, 240.00, 72.00, 72.00, 72.00, 240.00, 72.00, 240.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 72.00, 240.00, 72.00, 72.00, 72.00 Manifest Placed Resolution Unit : Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches, Inches Manifest Reference Instance ID : uuid:CCEE4C04581511DCBA709A96E8487A91, uuid:35F7BF364E3311DC87D3FAAE982C94E1, uuid:9F3BD472756B11DD8CF4DD7D2077813E, uuid:EBF00C0506E111DD95E3AD6B1A096721, uuid:EBF00C0006E111DD95E3AD6B1A096721, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:F9E1793CCA18DE11BC3FA6C4C817A91E, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:F0E1793CCA18DE11BC3FA6C4C817A91E, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:1EB8B0DBC918DE11BC3FA6C4C817A91E, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:280103B6C918DE11BC3FA6C4C817A91E, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:6AF5C339C918DE11BC3FA6C4C817A91E, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:7CC56409C918DE11BC3FA6C4C817A91E, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:09D06BDA4FE611DC97A69E612307F86F, uuid:740379DDC518DE11BC3FA6C4C817A91E, uuid:09D06BDC4FE611DC97A69E612307F86F, uuid:CCEE4C04581511DCBA709A96E8487A91, uuid:DAAC3585725F11DC955CB5C89995C376 Manifest Reference Document ID : uuid:CCEE4C03581511DCBA709A96E8487A91, uuid:35F7BF354E3311DC87D3FAAE982C94E1, uuid:9F3BD471756B11DD8CF4DD7D2077813E, uuid:EBF00C0406E111DD95E3AD6B1A096721, uuid:DB16549A06DF11DD95E3AD6B1A096721, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:F8E1793CCA18DE11BC3FA6C4C817A91E, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:26B8B0DBC918DE11BC3FA6C4C817A91E, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:1DB8B0DBC918DE11BC3FA6C4C817A91E, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:270103B6C918DE11BC3FA6C4C817A91E, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:69F5C339C918DE11BC3FA6C4C817A91E, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:7BC56409C918DE11BC3FA6C4C817A91E, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:09D06BD94FE611DC97A69E612307F86F, uuid:730379DDC518DE11BC3FA6C4C817A91E, uuid:09D06BDB4FE611DC97A69E612307F86F, uuid:CCEE4C03581511DCBA709A96E8487A91, uuid:DAAC3584725F11DC955CB5C89995C376 Metadata Date : 2009:08:24 12:49:52-05:00 Creator Tool : Adobe InDesign CS3 (5.0.4) Thumbnail Format : JPEG Thumbnail Width : 256 Thumbnail Height : 256 Thumbnail Image : (Binary data 7939 bytes, use -b option to extract) Format : application/pdf Title : IHS Loan Repayment Program Application Handbook Description : Indian Health Service Loan Repayment Program Creator : Indian Health Service Subject : Indian Health Service, Loan Repayment, IHS Loan Repayment, LRP, LRP Application Producer : Adobe PDF Library 8.0 Trapped : False Page Count : 48EXIF Metadata provided by EXIF.tools