Form 827 E - J-1 Visa Waiver Physician Verification Of Employment

Form 827 E - J-1 Visa Waiver Physician Verification Of Employment - 2012 Page 2

J-1 VISA WAIVER PHYSICIAN VERIFICATION OF EMPLOYMENT FORM

Form #827E

(Form located on the Primary Care page of the MSDH website)

PURPOSE

The purpose of this form is to verify the employment status of J-1 VISA Waiver Physicians

recommended for approval by the Mississippi State Department of Health. The physicians

are required to work at least three years (or more if stated in contract agreement) at the

sponsoring medical facility approved practice site(s).

INSTRUCTIONS

J-1 VISA Waiver Physicians recommended for approval by the Mississippi State Department

of Health and a representative of the medical facility sponsoring the J-1 VISA Waiver

Physician should complete and submit the form to the Primary Care Office (PCO) once the

physician begins employment with the sponsoring medical facility and annually thereafter.

The PCO will mail the form to the active J-1 Physicians in the PCO database. This Form

Must Be Notarized.

The following should be provided on the form:

Section I

Check type of J-1 VISA Waiver Program.

The J-1 VISA Waiver Physician should provide contact information in Section I. Information

includes the physician’s name, complete home address, home telephone number, cell

phone number, and email address.

Also in Section I, the J-1 VISA Waiver Physician should provide approval dates of the J-1

VISA Waiver and H-1B.

Section II

The J-1 VISA Waiver Physician should provide the following for the sponsoring medical

facility practice site(s): facility name, complete address, and telephone number.

Section III

J-1 VISA Waiver Physician must certify working 40 hours per week providing health services

at the medical facility practice site(s) listed in Section II.

Section IV

A representative of the sponsoring medical facility must certify that the J-1 VISA Waiver

Physician is or is not working at the practice site(s) listed in Section II.

Revised 01/05/2012

Form 827 E - J-1 Visa Waiver Physician Verification Of Employment - 2012 Page 2