New York "State 30" Program Application Cover Sheet Page 3
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3V. PATIENT ORIGIN DATA FOR PHYSICIANS NOT PRACTICING IN HPSAs OR MUA/Ps
The purpose of this section is to collect information on the origin (home residence) of patients whom the physician listed in Section I
serves (or is likely to serve) IF the physician DOES NOT propose to practice at least 40 hours per week in a HPSA or MUA.
In the box below, please list the HPSA, MUA or MUP of all patients served by the physician listed in Section I. Use the most recent
12-month period for which data is available. Indicate the 12-month period below.
If the physician for whom the waiver is requested is NOT currently employed at the site listed in Section III, please estimate visit data
based on visits provided by one currently or recently-employed physician practicing in a similar specialty at the site listed in Section III.
IF THAT IS NOT POSSIBLE, THEN estimate visits provided by one currently or recently-employed physician practicing in a similar specialty
at another similar site.
In Column 1, list the HPSA, MUA or MUP in which the physician’s patients reside. Continue filling out the rows until all patients residing in
HPSAs, MUAs or MUPs are accounted for. In column 2, list the 12-month total of visits from all patients in column 1. Provide the subtotals
and total as listed below. Add additional pages (formatted as in the table below) as necessary. COUNT PATIENT VISITS FOR THE PHYSICIAN
ONLY ; DO NOT LIST ALL VISITS FOR THE SITE OR FACILITY. Please answer all questions as accurately and specifically as possible.
Column 1
Column 2
12-month Number of Visits
Name of HPSA, MUA or MUP
from Residents in Column 1
1. SUBTOTAL Visits from patients residing in HPSAs/MUA/Ps (Column 2 total)
0
2. SUBTOTAL Visits from patients NOT residing in HPSAs/MUA/Ps
3. TOTAL All patient visits provided by physician (Subtotal 1 + Subtotal 2)
0
CHECK ONE
Visit data above refers to services provided by actual physician for which the waiver is requested.
Visit data above refers to services provided by another physician in a similar specialty at the site listed in III above.
Visit data above refers to services provided by another physician in similar specialty at another, similar site.
12-month period for above data ____________________________________________________________________________
Name ______________________________________________________________________
Source/contact for above data
–
–
Phone Number
DOH-4371 (8/16) Page 3 of 3
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