Application For Washington State J-1 Physician Visa Waiver Program Page 7
Download a blank fillable Application For Washington State J-1 Physician Visa Waiver Program in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Washington State J-1 Physician Visa Waiver Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Page 5 of 7
A service requirement of not fewer than three years from employment start date
Statement that the physician will work not fewer than 40 hours per week providing direct clinical patient
services in the HPSA or, in the case of a practice location without a HPSA designation, to residents of
HPSAs
Statement that the physician will begin employment within 90 days from the date of the granted waiver
Identification of the wages to be paid to the physician
Description of the physician’s duties
Description of the working conditions of the practice opportunity, including the facilities provided,
malpractice insurance coverage, leave benefits, opportunities for continuing medical education, and other
employee benefits
Statement that the physician will provide physician services to Medicare recipients, Medicaid recipients,
other low-income patients, and uninsured patients
Statement that the physician must see all patients, regardless of ability to pay, based on a sliding fee
discount schedule implemented by the applicant
Statement that the applicant cannot prevent the physician from providing clinical patient services in the
designated shortage area after the term of employment
Statement by the physician that he or she agrees to meet the requirements set forth in Section 214(l) of the
Immigration and Nationality Act
13. Does the contract include any handwritten notes or changes? ☐Yes ☐No
Documentation Required: All handwritten changes, notes or comments to the contract must be initialed and
dated by both the physician as well as the person authorized by the applicant to sign the contract. Each copy of the
contract must contain initials and dates.
14. Is the applicant offering the physician named in the visa waiver application the same working
conditions and salary that it would have otherwise offered to a physician who graduated from a U.S.
medical school? ☐Yes ☐No
Documentation Required: The working conditions and salary must be outlined in the employment contract
between the applicant and the physician.
Proposed schedule for physician
Weekday
Work hours
Location
Total hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Proposed call schedule:
DOH 346-003 September 2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal