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Texas Higher Education Coordinating Board

ST. DAVID’S FOUNDATION PUBLIC HEALTH CORPS LOAN REPAYMENT PROGRAM Enrollment Application

Please carefully read the following information before competing your application.

The purpose of the St. David’s Foundation Public Health Corps Loan Repayment Program is to recruit and retain qualified primary care and behavioral health providers at eligible safety net sites located in the five-county area served by the Foundation. If you are selected for enrollment into the program, loan repayment funds will be reserved for annual disbursement at the end of each of the four years of service, contingent upon continued annual grant funding. We will mail the appropriate documents to you toward the end of each year of service, for your employer’s verification of your service and for your lender’s verification of loan information.

We will notify you by postal mail and e-mail regarding the disposition of your application.

PROVIDER ELIGIBILITY REQUIREMENTS 1) All providers must be a U.S. citizen or permanent legal resident (or otherwise be legally authorized to work in the United

States), practice an approved practice specialty, and agree to provide four years of service at an approved practice site (outpatient primary care or behavioral health facility) NOTE: Funding under this program is currently only provided for the first year of service. Provider will be released from this agreement if grant funding is not continued for subsequent years of service.

2) Physicians must have a current unrestricted license from the Texas Medical Board and be board certified or eligible to take the

exam from an American Specialty Board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists.

3) Dentists must have an unrestricted license from the Texas State Board of Dental Examiners.

4) Physician Assistants must be certified by the National Commission on Certification of Physician Assistants (NCCPA) or be eligible to take the exam offered by the NCCPA and work under the direction of a physician in the area of primary care and/or behavioral health.

5) Nurse Practitioners must be licensed as a Nurse Practitioner in the area of primary care and/or behavioral health or be eligible to take the exam offered by a national certifying body recognized by the Texas Board of Nursing and work under the direction of a physician in the area of primary care and/or behavioral health.

APPROVED PHYSICIAN SPECIALTIES OTHER APPROVED PROVIDERS

Family Practice/Family Medicine

Internal Medicine

Pediatrics

OB/GYN

Geriatrics

Psychiatry

General Dentists

Pediatric Dentists

Primary Care Physician Assistants

Behavioral Health Physician Assistants

Primary Care Nurse Practitioners

Behavioral Health Nurse Practitioners

ELIGIBLE PRACTICE SITES

All clinical sites must be either tax-exempt under section 501(c) (3) of the Internal Revenue Code (e.g. primary care clinic, FQHC as defined below), a local mental health authority, or a governmental/public health facility (e.g. outpatient clinic, state psychiatric hospital). Sites must be located in Bastrop, Caldwell, Hays, Travis, or Williamson County and have a primary focus on serving the underserved, including Medicaid, CHIP, Medicare, and other low-income under-insured or uninsured populations. All sites that are eligible to participate in National Health Service Corps (NHSC) programs must have submitted an NHSC site application and be approved for participation in that program. The following are listed in order of priority:

1) St. David’s Foundation-funded grant partner sites that are not Federally Qualified Health Centers (FQHCs)

2) St. David’s Foundation-funded grant partner sites that are FQHCs

3) FQHCs and other nonprofit primary care and/or behavioral health sites that are not St. David’s Foundation grant partners

SERVICE PERIOD

The provider must serve for at least 12 consecutive months at an approved practice site to qualify for an annual loan repayment award. The first service period begins on the first day of the month in which the application is received.

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MAXIMUM ANNUAL AWARD AMOUNTS

If the loan balance is less than the applicable maximum annual award amount (as shown below) times 4, then the annual amounts will be prorated to retire the balance over a period of four years (contingent upon continued annual grant funding). Awards will also be prorated to the extent the provider is only providing a part-time service (as further discussed in Section C of this application). Otherwise, the maximum annual award amounts are as follows:

Physicians: $30,000 Dentists: $30,000 Physician Assistants: $15,000 Nurse Practitioners: $15,000

PRIORITIES AND PREFERENCES

If the number of qualified applicants exceeds available funding, priority will be given to physicians and dentists.

Preference will be given for:

New hires and/or providers who completed training within the past 2 years Bilingual providers (with preference for languages of the underserved populations, such as Spanish and Vietnamese)

LOANS ELIGIBLE FOR REPAYMENT

To be eligible for repayment, an education loan must:

1) Be evidenced by a promissory note to pay for the cost of attendance for the provider’s undergraduate or graduate education

at an accredited institution in the United States. Loans made during residency are not eligible. If the loan has been consolidated with other loans, the applicant must provide documentation of the portion of the consolidated debt that was originated to pay for the cost of attendance for the provider.

2) Not have an existing service obligation and must not be subject to repayment through another student loan repayment or

loan forgiveness program. I acknowledge that I have read and understand the above.

Signature: Date Signed:

APPLICATION INSTRUCTIONS

1) The applicant must signed the acknowledgement above and complete Sections A and B; the employer must complete Section C

2) The application may be mailed or faxed to: Texas Higher Education Coordinating Board, PO Box 12788, Austin, Texas

78711-2788 Fax (512) 427-6423

PRIVACY ACT NOTICE

Certain information required on the application is made confidential by the Privacy Act of 1974 (5 USC 552a). The requested information is necessary for participation in the St. David’s Foundation Public Health Corps Loan Repayment Program, to verify your identity and to determine your eligibility for the program and for any benefits from it. The Privacy Act provides that an agency may continue to require disclosure of an applicant's Social Security Number (SSN) as a condition for the granting of a right, benefit, or privilege if the agency required this disclosure prior to January 1975. The Texas Higher Education Coordination Board has, for years prior to 1975, required the disclosure of the SSN of all applicants for the programs that it administers. The SSN may be used to verify your identity and as an account number (identifier) throughout your eligibility in the program, in order to make certain that THECB records necessary data accurately. As an identifier, the SSN will be used to determine program eligibility.

The following notices are provided in accordance with Texas Government Code, Section 559.003(a):

1) With few exceptions, you are entitled on request to be informed what information THECB collects about you, and to receive

and review the information. 2) Under Section 559.004 of the Government Code, you are entitled to have THECB correct information about you that is

incorrect. You may do so by writing to St. David’s Foundation Public Health Corps Loan Repayment Program, Texas Higher Education Coordinating Board, P.O. Box 12788, Austin, Texas 78711.

3) The information that the Texas Higher Education Coordinating Board collects will be retained and maintained as required by Texas record retention laws (Texas Government Code, Section 441.180 et seq.) and rules. Different types of information are kept for different periods of time.

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Section A – Applicant Information Social Security #: Date of Birth: Name: Any Prior Names: Home Address: Home Phone #: ( ) Other Phone #: ( ) E-mail: City County Zip Type of Provider: Primary Care Physician Psychiatrist General Dentist Pediatric Dentist

Primary Care Physician Assistant Behavioral Health Physician Assistant Primary Care Nurse Practitioner Behavioral Health Nurse Practitioner

If primary care physician, indicate practice specialty:

Family Medicine Internal Medicine Pediatrics OB/GYN Geriatrics

Texas License No.:

Board Certified Eligible to take the board certifying exam as described on page 1 If you speak a foreign language, state the language: Proficiency: Fair Good Excellent Ethnic Origin (to be used for demographic reporting purposes only)

Hispanic or Latino origin Not Hispanic or Latino origin Race (to be used for demographic reporting purposes only)

White African American, Black Asian Native Hawaiian or other Pacific Islander American Indian or Native Alaskan Other

Provide the following information for all student loans that you obtained to pay for undergraduate, graduate, or medical education. Loans obtained during residency training or for post-medical school costs are ineligible.

Priority 1

Priority 2

Priority 3

Priority 4

Priority 5

Lender/Servicer

Loan Type/Program

Estimated Loan Balance

Section B – Certifications

I represent, warrant, and certify the following:

1. I am a U.S. citizen or a Legal Permanent Resident (or am otherwise legally authorized to work in the United States) and hold a full license, with no restrictions, to practice my profession in the State of Texas.

2. I meet all program eligibility requirements, including the requirement that I am not currently fulfilling another obligation to provide medical services as part of a

scholarship agreement, a student loan agreement, another student loan repayment agreement, or an employment agreement.

3. I agree to provide four years of continuous service as a provider at the eligible clinical site described in Part C of this application, with the understanding that I will be released from this agreement if grant funding is not continued beyond current year funding.

4. By my signature below, I authorize my employer to release information regarding my employment to the THECB and I authorize the THECB to share my

application information (including any student loan records submitted by either myself or my lender relating to this program) with the St. David’s Foundation, with the understanding that THECB and/or the St. David’s Foundation (and any of their respective agents) may contact me in the future regarding my participation in this program and may use this information for purposes of reporting, auditing, and evaluating the impact of this program.

5. The information contained in all parts of this application is true and correct to the best of my knowledge.

6. I understand that (A) upon acceptance of the application, all information submitted with the application becomes subject to disclosure under the Texas Public

Information Act (Texas Government Code Section 552.001 et seq.), unless an exception under the Texas Public Information Act is applicable and (B) the loan repayment awards are disbursed annually following my completion of 12 months of continuous eligible service and are contingent upon continued grant funding.

7. The information contained in all parts of this application is true and correct to the best of my knowledge.

Signature: Date Signed: Warning: A person submitting misleading or fraudulent information to the Texas Higher Education Coordinating Board in an attempt to obtain financial aid is subject to criminal prosecution. of 4 Rev 20140212



Section C – Employment Verification – to be completed by the facility’s Chief Administrator Facility Description (Check all that apply) SDF Grant Partner Name of Applicant Federally Qualified Health Center Name of Employer Public Non-Profit Name of Facility (if different from above) Private Non-Profit Facility Street Address Approved for NHSC Programs City State Zip Participating in NHSC Programs County Facility Phone Number Not Participating in NHSC Programs Beginning date of employment at this facility: Provider’s position and practice specialty: Note: Full-time clinical practice is defined as a minimum of 32.5 hours per week. Awards for eligible part-time service (minimum of 20 hours of direct patient care) will be pro-rated. Please do not include on-call time. Average total number of hours per week the provider serves at this facility: Average number of hours per week the individual provides direct patient care at this facility: Number of sites where the provider practices: Please describe any other foreign language skills, cultural understandings, or qualities that enhance the provider’s ability to serve the patients at your clinic in a manner that is highly valuable.

Please describe the clinic’s income by source of payment:

Source of Payment

CHIP % Medicaid % Medicare % Private Insurance % Uninsured/self-pay % Total 100% I represent, warrant, and certify that: (a) the practice facility named above meets the eligible practice site described on page 1 of this application and (b) the above information is true and correct. I understand that I will be asked to provide patient encounter data for this provider when I verify completion of the year of service. ( ) Designated Official’s Printed Name and Title Phone Number ( ) Email Address Fax Number Designated Official’s Signature Date Signed Warning: A person submitting misleading or fraudulent information to the Texas Higher Education Coordinating Board in an attempt to obtain financial aid is subject to criminal prosecution. Page 3 of 4 Rev 20140212

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