64W-1.004. Application Requirements

(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 8½ꞌꞌ x 11ꞌꞌ 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 8½ꞌꞌ x 11ꞌꞌ 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. History–New 8-12-21, Amended 10-24-22.