Current through Reg. 50, No. 187; September 24, 2024
(1) The
following Conrad 30 Waiver Program documents must be completed and submitted to
the Department to be evaluated for sponsorship:
(a) A Florida DOH Sponsorship Application
(DH8006-PHSPM-07/2022), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-14708;
(b) A Physician Agreement
(DH8007-PHSPM-07/2021), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-13375;
(c) Physician Attestation of Exclusivity
(DH8008-PHSPM-07/2021), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-13376;
(d) Employer Practice Location Attestation(s)
(DH8009-PHSPM-07/2022), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-14709;
(e) A Specialist Addendum
(DH8010-PHSPM-07/2021), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-13378,
is required if the physician is not a Primary Care Physician, as defined in
subsection 64W-1.002(6),
F.A.C.;
(f) A Flex Addendum
(DH8011-PHSPM-07/2021), incorporated by reference and available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-13379,
is required for every practice site that is not located in a designated
HPSA;
(g) Practice Facility Cover
Letter;
(h) A copy of Employment
Contract;
(i) Evidence of Shortage
Designation Status: A copy of the HRSA "Find Shortage Areas by Address" query
result for each practice site location;
(j) A copy of the applicant's clear, active
Florida medical license;
(k)
Physician Curriculum Vitae;
(l) A
copy of the Physician's Statement of Reason, as submitted as part of the USDOS
Form DS-3035;
(m) A copy of USDOS
Form DS-3035 with all bar code pages, as received from the USDOS;
(n) A copy of applicable USDOS Form
DS-2019/IAP-66, as received from the USDOS; and
(o) A copy of USDOS Form G28, as submitted
with USDOS Form DS-3035.
(2) All Department forms for the Conrad 30
Waiver program will also be made available on the Department's website at
http://www.floridahealth.gov/provider-and-partner-resources/community-health-workers/conrad-30-program-j-1-visa/index.html
on or before July 1 each year and shall stay on the Department's website until
sponsorship notification has occurred to all applicants.
(3) Application packets must:
(a) Include the applicant's USDOS case number
on the bottom right corner of each page in the submission packet, excluding the
Florida DOH Sponsorship Application, to assure accurate review and processing
at the USDOS and the USCIS;
(b)
Include a table of contents and 81/2'' x 11'' colored section dividers to
assure accurate review and processing at the USDOS and the USCIS. The
application packet must not have tabs that exceed the 81/2'' x 11''
size;
(c) Not use staples or
two-prong fasteners. Binder clips and rubber bands are acceptable;
and
(d) Only include one copy of
the application packet materials. Additional copies will be
shredded.
Rulemaking Authority 381.4018(3) FS. Law Implemented
381.4018 FS.
New 8-12-21, Amended
10-24-22.
