Clinical Care Waiver Request Requirements (Supplement B)

General Requirements

For general requirements see Exchange Visitor Program. All requirements are consistent with the Federal Register Notice that govern requests for waivers for the delivery of health care services.

Physician Eligibility

HHS will process an application for waiver for a physician to practice in a primary care (family medicine, general internal medicine, general pediatrics, obstetrics & gynecology) or general psychiatry who have completed their primary care or psychiatric residency training programs no more than 12 months before the date of commencement of employment under the contract.

Facility Eligibility

In order to target communities and populations with the greatest need for primary care and mental health services, HHS will only process an application for waiver from a facility in or with a health professional shortage area (HPSA) score of 07 or higher.

Note to Employers

If you have a position posted on the National Health Service Corps (NHSC) Opportunities List, you may only offer that position to a J-1 visa physician in the event that it remains unfilled by an NHSC scholar or loan repayment eligible physician for placement at the end of the NHSC Placement Cycle.

Application Package

A complete application package consists of the completed supporting documentation below. One non-stapled copy is needed.

Required Supplemental Information

Physician Requirements

1. Department of State Data Sheet (2 copies)
2. Readable copies of J-1's IAP-66 and/or DS 2019 forms for each year in J-1 status
3. IMG Physician Statement [see 22 CRF Chap.1, Sec. 41.63(c)(4)(iii)]. MUST be in exactly this format:
   
   "I, (insert Name of exchange visitor) hereby declare and certify, under penalty of the provisions of 18 U.S.C. 1001, that I do not now have pending nor am I submitting during the pendency of this request, another request to any United States Government department or agency or any State Department of Public Health, or equivalent, other than (insert Name of U.S. Government Agency requesting waiver) to act on my behalf in any matter relating to a waiver of my two-year home-country physical presence requirement." Statement must be signed by the physician and dated.
4. Current Curriculum Vitae (CV). Do not include your Social Security number
5. Credentials (diplomas, licenses / license application): Showing completion of a residency in one of the following: family practice, general pediatrics, obstetrics/gynecology, general internal medicine, or general psychiatry and board certified or board eligible in primary care discipline in the last 12 months.

Employer Requirements

1. Completed HHS Application Form HHS 426 – Application for Waiver of the Two-Year Foreign Residence Requirement of the Exchange Visitor Program – PDF
2. Submitter's cover letter and G-28 – PDF
3. Letter of need from medical facility, signed and dated by the director of the medical facility on the facility's letterhead. Letter should include the HPSA or MUA identifier number of the federally-designated underserved area where the facility is located. If the physician is to work at more than one site, HPSA or MUA identifier numbers for all sites needs to be included. The letter should also include that the facility:
   • treats all patients regardless of their ability to pay,
   • accepts Medicare, Medicaid, and S-CHIP assignment,
   • uses a sliding fee scale, and
   • may charge no more than the usual and customary rate prevailing in the geographic area in which the services are provided.

1. Three letters of community support for the hire of this physician (including contact information)
2. State health department support/acknowledgment letter (If letter has not been received, enclose a copy of the facility's request for the letter. The letter may be forwarded under separate cover when received.)
3. Copy of executed contract signed by the head of the medical facility and the physician, dated, and notarized. Contract must:
   • be of three years' duration,
   • obligate the physician to begin work within the first three months of receiving the waiver approval,
   • obligate the physician to work 40 hours per week providing primary care (family practice, general internal medicine, general pediatrics, or obstetrics/gynecology) or general psychiatric services,
   • specify the site in which the physician will work (if more than one, all sites must be located in designated health professional shortage areas (HPSAs) with a score of 7 or higher, and HPSA identifier numbers must be provided), and
   • include a clause that the contract can only be terminated for cause until completion of the three-year commitment. NOTE: Contract may not contain a non-compete clause or restrictive covenant.
4. Prevailing wage information
5. Evidence of employer's regional and national recruitment efforts, including names of non-foreign physicians applying and/or interviewed and reasons why they were not hired
6. Proof of facility's existence (Additional documentation may be required).

For questions Clinical Care Waiver Requirements (Supplemental B) contact:

Michael Berry
Bureau of Health Workforce
Health Resources and Services Administration
Department of Health and Human Services
(301) 443-4154