STATE-30 J-1 VISA WAIVER PROGRAM

STATE-30 J-1 VISA WAIVER PROGRAM KATHLEEN SEBELIUS, GOVERNOR RODERICK L. BREMBY, SECRETARY KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT OFFICE OF LOCAL AND RURAL HEALTH AUGUST 30, 2003

STATE-30 J-1 WAIVER REVIEW PROGRAM OF KANSAS PROGRAM OBJECTIVES... 1 DESCRIPTION OF WAIVER REVIEW PROCESS... 1 REQUIREMENTS... 2 LIMITATIONS... 3 PHYSICIAN RECRUITMENT... 4 CONTRACTS... 4 REPORTING REQUIREMENTS... 5 PENALTIES FOR DEFAULT... 5 APPENDIX OVERVIEW OF STATE DEPARTMENT PROCEDURES... 7 UNDERSTANDING THE TWO-YEAR FOREIGN RESIDENCE REQUIREMENT... 8 BASIS FOR OBTAINING A WAIVER TO THE REQUIREMENT... 9 KANSAS J-1 VISA WAIVER APPLICATION CHECKLIST... 10 EVALUATION PROCESS FOR STATE 30 J-1 VISA WAIVER APPLICATIONS.. 12 SLIDING-SCALE FEE SCHEDULE AND ELIGIBILITY INFORMATION.13 FORMS STATE-30 J-1 VISA WAIVER PROGRAM AFFIDAVIT AND AGREEMENT... 14 U.S. DEPARTMENT OF STATE EXCHANGE VISITOR ATTESTATION.15 U.S. DEPARTMENT OF STATE EMPLOYER ATTESTATION... 16 KANSAS PHYSICIAN/EMPLOYER REPORTING FORM... 17

RODERICK L. BREMBY, SECRETARY K A N S A S DEPARTMENT OF HEALTH AND ENVIRONMENT KATHLEEN SEBELIUS, GOVERNOR STATE-30 J-1 WAIVER REVIEW PROGRAM OF KANSAS PROGRAM OBJECTIVES The State 30 (Conrad) J-1 Visa Waiver Program assists in the recruitment and retention of physicians serve communities that lack adequate access health care. The State 30 J-1 Visa Waiver Program assists non-citizen physicians who are international medical graduates obtain an H-1B or L-1 visa by waiving the two-year home country residency requirement in exchange for a commitment practice medicine in a location designated as a Health Professional Shortage Area (HPSA) providing a justifiable need for the State of Kansas intercede on behalf of its residents. International Medical Graduates (IMGs) are physicians from other countries who have sought and received a J-1 exchange visir visa. The visa allows holders enter clinical training programs and remain in the U.S. until completion of their studies. At the completion of their program of study, immigration law requires that they return their home countries for two years before applying for re-entry in the United States. The State 30 J-1 Visa Waiver Program was created under the Immigration and Nationality Act, Title III, 22 CFR 41.63. Also known as the Conrad 30, this program allows public health departments of state government establish rules and policies that comply with immigration law and serve in the same way as federal agencies served as the interested government agency (IGA) for requesting waivers of Section 212(e) of the Immigration and Nationality Act, the provision requiring the two-year home-country physical presence for individuals who are in the United States on J-1 exchange visir visas. It is important note that the waiver of the two-year residence requirement is not a visa. Physicians going through the state waiver program are eligible for and must make an application the INS for H1B visa status. Permanent residence visa status will not be permitted until the physician s three years of obligary service in a health professional shortage area have been fulfilled. You may want seek legal counsel assist you in the preparation and submission of the required INS forms and documentation. DESCRIPTION OF WAIVER REVIEW PROCESS The Governor of the state of Kansas has designated the Kansas Department of Health and Environment (KDHE) as the agency review applications and make recommendations the Waiver Review Division of the U.S. Department of State. The Waiver Review Division then makes recommendations the Bureau of Citizenship and Immigration Services (BCIS, the former Immigration and Naturalization Service) concerning such waivers. Page 1

KDHE action is limited recommending that a waiver be granted where it furthers an agency policy. This action is discretionary and is not the equivalent of granting the waiver. Eligible applicants may request an instruction packet detailing the information required by KDHE. The materials will also be available download from the agency website at: http://www.kdhe.state.ks.us/olrh/j-1visa_waiver.html Application processing may involve direct contact with immigration atrneys and/or the candidate if the applicant agrees. An eligible practice site must be located in a medically underserved community designated by the US Department of Health and Human Services (DHHS) as a primary care or mental health care Health Professional Shortage Area (HPSA), or a recently designated Medically Underserved Area (MUA), or the practice site must serve a Medically Underserved Population (MUP). Only the number of primary care physicians needed eliminate a Health Professional Shortage Area designation will be recommended. Specialty requests are considered on a case by case basis and shall not exceed 20% of tal waivers available the state annually. Requests should be submitted approximately six months before the J-1 physician s current educational program is scheduled for completion. Incomplete requests will be held for review until all required documents are received. The review cycle begins on Ocber 1 with complete applications numbered sequentially beginning with one (1) each year. After thirty (30) case numbers are assigned, the remaining cases will be assigned a priority number and carried over the next fiscal year for processing. REQUIREMENTS The federal government now mandates that all J-1 Visa Waiver applicants must apply for a case number from the U.S. Department of State. This federal regulation requires completing and submitting a Data Sheet that may only be obtained through the U.S. Department of State. (See Appendix, for U.S. Department of State requirements) Kansas participation in the waiver program is intended assist local communities assure that their residents have access physician services. The program focuses on primary care defined as general medicine, internal medicine, family practice, general pediatrics, obstetrics/ gynecology, emergency medicine and psychiatry. However, a limited number of sub-specialists may be recommended annually, up 20% of the tal authorized. In addition the primary care shortage designation for the practice location, evidence of unmet need for non-primary care specialties must be demonstrated by the applicant. This may include past utilization data, population physician ratios, waiting times for referrals from safety net providers, medical school faculty vacancy, or other measures of underservice. Application must be made by the legal entity making the contract offer the physician seeking a J-1 visa waiver, including facilities, institutions, rural health clinics, community health centers, primary care clinics, medical centers, hospitals or private practices located in Kansas. Applications will only be accepted when there is a confirmed physician contract pending. Page 2

Waiver requests must be submitted the Kansas Department of Health and Environment by the employer or the employer s representative. The letter of need must be written on the employer s letterhead stationery, which includes the address, phone number, and fax number, if any. Letters of need and forms must contain original signatures. The employer must show evidence of open recruitment and that hiring a J-1 physician is a last resort. A physician not encumbered by the J-1 home residence requirement, who applies for and is qualified for the job advertised, must be offered the position. The medical practice must be located in a HPSA or an MUA with a designation in the past 3 years. Evidence should include the street address, fax and telephone numbers for the practice site. The facility must accept all patients regardless of ability pay. The J-1 physician must have or be eligible for a medical license from the Kansas Board of Healing Arts. (Website http://www.ksbha.org/ ) The J-1 physician is responsible for negotiating a contract for a minimum of 3 years provide care at least 40 hours per week, at least 4 days per week, in the appropriate specialty. By federal regulation, the J-1 physician must commence practice within 90 days of receiving a waiver. The U.S. Department of State and the Bureau of Citizenship and Immigration Services will be notified if a J-1 physician is found not have reported or not be practicing medicine at least 40 hours per week in the location for which the recommendation was made. KDHE must be notified when the J-1 physician does not report for duty. The employer and/or J-1 physician must notify KDHE of any breach or termination of contract. Transfers must be cleared with KDHE before the transfer occurs so that it can be determined if the new area is also underserved. Requests for a J-1 physician practice in a population-designated HPSA or an MUP must show that it posts a sliding-scale fee schedule and income eligibility information in its waiting room (see Appendix page ***). The waiver request must contain letters of community support from each of the following: community leaders (mayor, commissioners, other elected officials, chamber of commerce, etc.) local physicians, local hospital administrar(s), and the county health department. Limitations: Requests will be limited two per employer or affiliated practice during each annual cycle. The cycle shall be Ocber 1, 2003 September 30, 2004. A former J-1 physician currently fulfilling his/her required 3-year obligation may not serve as the employer of a new waiver candidate. KDHE will not accept applications recommend a waiver for a relative or acquaintance of the employer. Physician Recruitment: KDHE policy is that a waiver recommendation by the state public health agency is a measure of last resort. As such, the medical facility must prove that other avenues, regionally and nationally, Page 3

secure a physician not bound by the 2- year home residence requirement have been undertaken over a period of at least the six months prior preparing/signing a contract. Recruitment efforts must include regional and national print advertising stating the position available and the practice site location. One acceptable regional recruitment effort is list the position in Kansas Connections a quarterly newsletter and placed on the University of Kansas Medical School website for Kansas Healthcare Job Opportunities. Job information is available from the Rural Health Education and Services of the University of Kansas School of Medicine and is accessible at http://ruralhealth.kumc.edu or by calling 1-888-503-4221. Contracts: The contact must include all of the following information: a) guaranteed 3-year base salary b) benefits c) health insurance d) field of practice, practice site name and complete street address e) 40 hours for at least 4 days per week, not including travel and on-call time e) leave (annual, sick, continuing medical education, holidays) f) commencement date begins within 90 days of receipt of J-1 visa waiver g) statement that amendments shall adhere State and Federal J-1 visa waiver requirements For the staturily-required 3 years, there can be no changes the contract that would result in the J-1 physician leaving the agreed-upon site or ceasing serve the patients he/she has agreed serve in the manner agreed upon. It is recommended that each party have its own legal representation in preparation of the contract. Other contract terms and conditions: May be terminated only with cause and cannot be terminated by mutual agreement until the staturily-required 3 years have expired. Must contain a sentence stating what field of medicine the J-1 physician will practice a minimum of 40 hours per week and the practice site address. Include the days and hours of practice, and a statement that on-call and travel times are not included in the minimum hours. A non-competition clause or any provision that purports limit the J-1 physician s ability remain in the area upon completion of the contract term is prohibited by regulation. May include a liquidation clause. However, any clauses that would require the J-1 physician pay a sum the employer for experience gained on the job or for the J-1 physician remaining in the area after the contract has ended are not allowed. Page 4

Reporting Requirements: The physician and the Chief Executive Officer of the employing entity must provide annual reports the KDHE Waiver Review Program (Appendix). The first report must be submitted within 30 days after employment begins, and every 12 months thereafter, until the 3 year commitment is complete. Further, in agreements serve in population-designated HPSAs, documentation must be submitted demonstrating that the relevant underserved population was indeed served. What constitutes adequate proof will vary depending upon the circumstances but should include a report of Medicare, Medicaid/HealthWave and self-pay revenue, and number of patients served by pay category, if available. When submitting the final report, the physician must indicate whether he/she intends remain in the shortage area practice. If a report is not submitted, penalties for default will be implemented. Although not required for submission, KDHE may request see copies of the following: position recruitments ads with visible publication date(s); advertising bills and payment receipts; contracts with recruitment firm(s) ; all other physician CVs submitted in response recruitment efforts; if an American citizen or permanent resident physician applied for the position, a detailed justification of why they were not hired; current Federal, state, or other published, recognized-source prevailing wage document; evidence that the J-1 physician selected for the position has visited the practice site (travel and hotel receipts, etc.); and, list of primary care physicians, including J-1 and H-1b, National Health Service Corp and State loan-repayment physicians, currently practicing in the HPSA. Ongoing site evaluation: KDHE will monir provider practice and patient access and follow up on any complaints that the practice refuses care patients. KDHE may use Medicaid claims data and waiting times for referrals from safety net providers if necessary monir access concerns. Past compliance with the program guidelines will affect an employer s future applications. Penalties for Default: Physicians - A letter Immigration and Naturalization Services with a recommendation for deportation. Employers - Restricted from submitting J-1 Visa Waiver applications for a period of two years. These requirements are subject revision without prior written notice. Page 5

Appendix Page 6

OVERVIEW OF STATE DEPARTMENT PROCEDURES On Ocber 1, 1999, the United States Information Agency (USIA) was integrated in the US Department of State. The Waiver Review Division of the Office of Legislation, Regulation and Advisory Assistance in the Visa Office of the Bureau of Consular Affairs (formerly the USIA Waiver Review Branch of the Office of the General Counsel) reviews applications and makes recommendations the Immigration and Naturalization Service concerning Section 212(e) waivers. The four steps processing a waiver review application, (Rev. June 6, 2002 ) may be found at: http://www.travel.state.gov/waiver_instructions.html Applicants must complete a Data Sheet (available via the Internet at http://travel.state.gov/ds-3035.pdf ) and send the completed Data Sheet, and two selfaddressed, stamped, legal-size envelopes and a check or money order for $230.00 U.S. dollars per application, payable the U.S. Department of State : If via Postal Service If via Courier Service US Department of State US Department of State Waiver Review Division Waiver Review Division (Box 952137) P.O. Box 952137 1005 Convention Plaza St. Louis, MO 63195-2137 St. Louis, MO 63101-1200 If you have questions regarding waiver review procedures, please refer one of the following sources of information: Consular Affairs website: http://travel.state.gov Visa Services: http://travel.state.gov/visa_services.html INS http://www.ins.usdoj.gov INS forms line: 1-800-870-3676 Waiver inquiries email: http://usvisa@state.gov General Public Inquiries 202-663-1225 You may check status of your application using your case number at: http://63.70.23.80/ When the Waiver Review Division receives ALL of the documentation requested, your case will be adjudicated. At the conclusion of the review process, the Waiver Review Division will forward its recommendation directly the Immigration and Naturalization Service and you will receive a copy of that recommendation at the address listed on your data sheet. If your application is denied, you will be notified directly. Downloaded 8/1/03 Check for Updates at: http://www.travel.state.gov/waiver_instructions.html Page 7

UNDERSTANDING THE TWO-YEAR FOREIGN RESIDENCE REQUIREMENT Exchange Visirs may be subject the two-year foreign residence requirement of Section 212(e) of the Immigration and Nationality Act, as amended, for one or more of the following reasons: 1. They received funding from the United States Government, their own government, or an international organization in connection with their participation in the Exchange Visir Program; 2. The education training, or skill that they are pursuing in this country appears on the Exchange Visir Skills List for their country; 3. They acquired J-1 status on or after January 10, 1977 for the purpose of receiving graduate medical education or training Education visirs who are subject, but do not wish comply with, the two-year home country residence requirement may apply for a waiver of that requirement under any one of five applicable grounds provided by United States immigration law. Page 8

BASIS FOR OBTAINING A WAIVER TO THE REQUIREMENT Exchange visirs who are subject, but do not wish comply with, the two-year home country residence requirement, may apply for a waiver of that requirement under any one of the five applicable grounds provided by the United States immigration law. 1. No Objection Statement The exchange visir s government, must state that they have no objection the exchange visir not returning the home country satisfy the two-year foreign residence requirement of Section 213(e) of the Immigration and Nationality Act, as amended, and remaining in the U.S. if he or she chooses do so. 2. Request by an Interested United States Government Agency If the exchange visir is working on a project for or of interest a U.S. Federal Government Agency and that agency has determined that the visir s continued stay in the United States is vital one of its programs, a waiver may be granted if the exchange visir s continued stay in the United States is in the public interest. NOTE: For applications on behalf of foreign physicians, who agree serve in medically underserved areas, please refer Federal Register (67 FR 77692) an interim-final rule amending amending the regulations at 45 CFR Part 50 governing the HHS Exchange Visir Program. 3. Persecution If the exchange visir believes that he or she will be persecuted upon return the home country due race, religion, or political opinion, he or she can apply for a waiver. 4. Exceptional Hardship a United States Citizen or Legal Permanent Resident Spouse or Child of an Exchange Visir If the exchange visir can demonstrate that his or her departure from the United States would cause extreme hardship his or her United States citizen or lawful permanent resident spouse or child, he or she may apply for a waiver. (Please note that mere separation from family is not considered be sufficient establish exceptional hardship.) 5. Request by a Designated State Health Department or Its Equivalent Pursuant the requirements of Public Law 103-416, of Ocber 25, 1994, foreign medical graduates who have an offer of full-time employment at a health facility in a designated health professional shortage area, and agrees begin employment at such facility within 90 days of receiving such waiver and signs a contract continue work at the health care facility for a tal of 40 hours per week and not less than three years, may obtain a waiver. In Kansas, the Kansas Department of Health and Environment (KDHE) Division of Health, (OLRH) is the designated state health department and administers the J-1 Visa Waiver Program (currently the Conrad State 30 Program) authorized by the Immigration and Nationality Act. Page 9

KANSAS J-1 Visa Waiver Application Form 7/30/03 Expires September 30, 2004 KANSAS J-1 VISA WAIVER APPLICATION CHECKLIST In order for Kansas Department of Health and Environment process your waiver request, a package of information must be compiled and submitted : Barbara Gibson, Direcr, State Primary Care Office KDHE 1000 SW Jackson, Suite 340 Topeka, KS 66612-1365 All information must be submitted AT THE SAME TIME. Record the Case Number assigned by Department of State on every sheet submitted Please avoid two-sided documents and use only 8 1/2" x 11" paper Required information be completed and supplied by the J-1 physician for the waiver review application packet: 9 1. A copy of the letter with the case number from the United States Department of State and a copy of the Department of State Data Sheet (DS 3035). 9 2. Readable phocopies of Physician s IAP-66 form or new DS-2019 ("Certificate of Eligibility for Exchange Visir (J-1) Status") covering every period during participation in J-1 visa status. 9 3. Readable phocopies of any I-94 Entry and Departure cards (front and back on the same page) for the physician and any family members, and proof of passage of examinations required by INS. 9 4. A letter with an explanation for any period spent: in some other visa status, out of status, or out of the country. 9 5. A personal statement regarding the exchange visir s reasons for not wishing fulfill the two-year country residence requirement. 9 6. Physician s curriculum vitae including the physician s social security number. 9 7. Qualifications (diplomas, licenses). 9 8. Copy of the physician s Kansas medical license, or demonstration that all medical licensure requirements are met for the State of Kansas. 9 9. Notarized Department of State Visir Attestation form. 9 10. Notarized KDHE Attestation form. 9 11. If foreign government funding was provided for the exchange visir program, request a no objection statement from the country which the J-1 visa physician is otherwise obligated return. However, the no objection statement must be sent directly the Waiver Review Division from the Embassy and must be on Embassy letterhead and stationery. Page 10

Required information be completed and supplied by employing entity/facility for the waiver review application package: 9 12. A letter addressed the Kansas Department of Health and Environment from the head of the entity/facility with whom the physician will be employed requesting that KDHE act as an Interested Government Agency and recommend a waiver for the J-1 physician. The letter must contain the following: Complete Address where physician will practice if the waiver is granted (county, street address, city and zip code, Description of the sponsoring employer facility or clinical site and the service area A list of all primary care physicians (or specialists) practicing in the area. For non-primary care specialties, detailed description of unmet need. A statement detailing the plans for retaining the physician during and beyond the 3-year obligation Applicant/Physician's Name Applicant/Physician's Date of Birth Applicant/Physician's Country of Origin or last residence Applicant/Physician's Medical Specialty The letter must also describe the physician s: qualifications, proposed responsibilities, and how the J-1 s employment will satisfy important unmet needs. 9 13. Copy of notarized, dated, executed contract for no less than 40 hours a week for three years between the facility and the J-1 physician, signed by both the head of the facility and the J-1 physician. Contract must statethat the J-1 physician agrees begin employment at such facility within 90 days of receiving the visa waiver. 9 14. Evidence of unsuccessful efforts for at least six months recruit an American physician for the position (i.e., medical journal advertisements, labor certifications, cover letters, stating that efforts recruit an American have been unsuccessful, etc.) 9 15. Letters of community support. 9 16. Letters of recommendation (three) from those who know the J-1 physician's qualifications. 9 17. Notarized U.S. Department of State Employer Attestation form signed by the head of the facility at which the J-1 physician will be employed stating that the facility: is located in a designated HPSA or recently designated MUA; and provides medical care Medicaid, HealthWave, and Medicare eligible patients, and indigent uninsured patients (Form, Page 16) Please enclose this check list with the waiver application package. KDHE will begin processing your application when all materials are available. Allow at least forty-five (45) days for the waiver request be processed by KDHE. Page 11

EVALUATION PROCESS FOR STATE 30 J-1 VISA WAIVER APPLICATIONS In addition compliance with requirements stated in the application materials, KDHE will consider the following program issues and guidelines: Kansas participation in the waiver program is focused on assisting local communities assure that their residents have access needed health care services Application must be made by the legal entity making the contract offer the physician seeking a J-1 visa waiver, including facilities, institutions, rural health clinics, community health centers, primary care clinics, medical centers, hospitals or private practices located in Kansas Application information will be provided by the KDHE a recruitment site when there is a confirmed physician candidate Primary care requests shall be given priority consideration Specialty requests are considered on a case by case basis and shall not exceed 20% of tal waiver recommendations available the state annually Satisfacry recruitment and retention efforts may be documented by Copies of advertisements List of interviewed candidates and reason not selected Notation and description of limited candidates in the region Evaluation of unmet need for health care services within the service area or for unmet need in an identified underserved population Number of practicing primary care physicians (or specialists, include visiting specialists, if applicable) For specialists, agreement of local primary care practitioners that the specialty is needed and support for the current waiver application Utilization data, e.g. number of procedures most commonly performed by specialty being recruited Population physician ratios, or other measures of underservice for the area Medicaid claims data if necessary monir access concerns Waiting times for referrals from safety net providers Past compliance with the program guidelines will be considered For medical school teaching positions, evidence of need shall consist of a letter from the Dean of the University of Kansas School of Medicine certifying that an essential faculty vacancy exists. Page 12

NUMBER IN HOUSE -HOLD 1 2 3 4 5 6 7 2003 and DISCOUNT ELIGIBILITY GUIDELINES * see source below ANNUAL 100% FPL: ANNUAL 100-149% FPL: ANNUAL 150-174% FPL: ANNUAL 175-199% FPL: ANNUAL 8 30,960 30,960 46,439 46,440 54,179 54,180 61,919 For family units with more than 8 members, add $3,140 for each additional member. (The same increment applies smaller family sizes also, as can be seen in the figures above.) MONTHLY NUMBER IN HOUSE- HOLD 1 2 3 4 5 6 7 8 NUMBER IN HOUSE- HOLD 1 2 3 4 5 6 7 8 8,980 12,120 15,260 18,400 21,540 24,680 27,820 100% FPL: MONTHLY 748 1,010 1,272 1,533 1,795 2,057 2,318 2,580 100% FPL: HOURLY 4.32 5.83 7.34 8.85 10.36 11.87 13.38 14.88 8,980 12,120 15,260 18,400 21,540 24,680 27,820 100-149% FPL: MONTHLY 748 1,010 1,272 1,533 1,795 2,057 2,318 2,580 100-149% FPL: HOURLY 4.32 5.83 7.34 8.85 10.36 11.87 13.38 14.88 * SOURCE: [Federal Register: February 7, 2003 Vol68, No.26, pp 6456-6458 [DOCID:fr07fe03-68] 13,469 18,179 22,889 27,599 32,309 37,019 41,729 1,122 1,514 1,907 2,299 2,692 3,084 3,477 3,869 13,470 18,180 22,890 27,600 32,310 37,020 41,730 15,714 150-174% FPL: MONTHLY 1,123 1,515 1,908 2,300 2,693 3,085 3,478 3,870 HOURLY 6.47 8.73 10.99 13.26 15.52 17.79 20.05 22.32 150-174% FPL: HOURLY 6.48 8.74 11.00 13.27 15.53 17.80 20.06 22.33 15,715 175-199% FPL: MONTHLY 175-199% FPL: HOURLY 200% FPL ANNUAL 200% FPL MONTHLY 200% FPL HOURLY Calculated monthly and hourly wages are for determining eligibility for programs or for fee reductions based on family income in the Charitable Health Provider and Farmworker Health Voucher Program The following table provides an example of a sliding-fee schedule 21,209 26,704 32,199 37,694 43,189 48,684 1,309 1,767 2,224 2,682 3,140 3,598 4,056 4,514 7.55 10.19 12.83 15.47 18.11 20.75 23.40 26.04 21,210 26,705 32,200 37,695 43,190 48,685 1,310 1,768 2,225 2,683 3,141 3,599 4,057 4,515 7.56 10.20 12.84 15.48 18.12 20.76 23.41 26.05 17,959 24,239 30,519 36,799 43,079 49,359 55,639 1,496 2,019 2,542 3,066 3,589 4,112 4,636 5,159 8.62 11.64 14.66 17.68 20.70 23.72 26.74 29.76 17,960 24,240 30,520 36,800 43,080 49,360 55,640 61,920 1,497 2,020 2,543 3,067 3,590 4,113 4,637 5,160 8.63 11.65 14.67 17.69 20.71 23.73 26.75 29.77 Discount Sliding- Fee Accounting Code 100% FPL: ANNUAL 100% Free care Sample DISCOUNT - SLIDING-FEE SCHEDULE 100-149% FPL: ANNUAL 75% Pay 25% of Charges 150-174% FPL: ANNUAL Pay 50% of Charges 175-199% FPL: ANNUAL P0 P1 Page 13 P2 P3 50% 25% Pay 75% of Charges 200% FPL ANNUAL 0% Pay Full Charges P4

KANSAS J-1 Visa Waiver Application Form 7/30/03 STATE-30 J-1 VISA WAIVER PROGRAM AFFIDAVIT AND AGREEMENT I, (please print), being duly sworn, hereby request that the Kansas Department of Health and Environment review my application for the purpose of recommending waiver of the foreign residency requirement set forth in my J-1 visa, pursuant the terms and conditions as follows: 1. I understand and acknowledge that the review of this request is discretionary and that in the event a decision is made not grant my request, I hold harmless the State of Kansas, the Kansas Department of Health and Environment, the Office of Local and Rural Health and any and all State of Kansas employees, agents, and assignees, from any action or lack of action made in connection with this request. 2. I further understand and acknowledge that the entire basis for consideration of my request is the Kansas Department of Health and Environment s voluntary policy and desire improve the availability of health care in medically underserved areas and populations with unmet needs.. 3. I understand and agree that in consideration for a waiver, which eventually may or may not be granted, I shall render medical care services patients, including the medically indigent, for a minimum of forty (40) hours per week within a U.S. Public Health Service designated primary care (or mental health) Health Professional Shortage Area (HPSA), Population HPSA, Medically Underserved Area (MUA) or Medically Underserved Population (MUP). 4. Such service shall commence no later than 90 days after I receive notification of approval by both the U.S. Immigration and Naturalization Service (INS) and the U.S. Department of Labor and shall continue for a period of at least three (3) years. 5. I agree incorporate all the terms of this "J-1 Visa Waiver Affidavit and Agreement" in any and all employment agreements I enter pursuant paragraph 3 (above). 6. I further agree that any employment agreement I enter pursuant paragraph 3 (above) not contain any provision which modifies or amends any of these terms of this "J-1 Visa Waiver Affidavit and Agreement." 7. I understand and agree that my medical care services rendered pursuant paragraph 3 (above) shall be in a Medicare and Medicaid certified site that has an open, non-discriminary admissions policy. If my practice site is located in a federally designated low-income HPSA, that practice site will use a sliding fee scale for low-income, medically indigent patients. 8. I understand that this waiver must ultimately be approved by the INS, and I agree provide written notification of the specific location and nature of my practice the Kansas Department of Health and Environment at the time that I commence rendering services and will notify the Kansas Department of Health and Environment of any change in the location and nature of my practice within three working days of the change or prior the change. 9. I understand and acknowledge that if I willfully fail comply with the terms of this J-1 Visa Waiver Affidavit and Agreement the Kansas Department of Health and Environment may notify the U.S. Department of State and the Immigration and Naturalization Service. Additionally, any and all other measures available the Kansas Department of Health and Environment may be taken in the event of non-compliance. I declare under the penalties of perjury that the information provided the Kansas Department of Health and Environment for purposes of determining whether it will act as an Interested Government Agency is true and correct. Signature Social Security # Date Subscribed and sworn before me this day of, 200. Notary Public Page 14

U. S. DEPARTMENT OF STATE EXCHANGE VISITOR ATTESTATION I, (please print) hereby declare and certify, under penalty of the provisions of 18 U.S.C. 1001, that I do not have pending, nor am I submitting during the pendency of this request, another request any United States Government department or agency or any other State Department of Public Health, or equivalent, other than the Kansas Department of Health and Environment, act on my behalf in any matter relating a waiver of my two-year home-country physical-presence requirement. Signature Date Subscribed and sworn before me this day of, 200. Notary Public Page 15 Kansas Department of Health and Environment CURTIS STATE OFFICE BUILDING, 1000 SW http://www.kdhe.state.ks.us/olrh July 30, 2003

KANSAS J-1 Visa Waiver Application Form 7/30/03 U.S. DEPARTMENT OF STATE EMPLOYER ATTESTATION I, (please print) hereby declare, under penalty of the provisions of 18 U.S.C. 1001, that (medical facility) is located in a primary care or mental health care Health Professional Shortage Area, ** ID#, Zip Code and provides medical care Medicare, Medicaid, and HealthWave patients and offers discounted fees medically indigent, uninsured patients. Signature Date Subscribed and sworn before me this day of, 200. Notary Public ** Current HPSA Identification Number may be found at: http://bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm If the application is for an MUA or MUP it must have a designation date within the past 3 years Page 16

KANSAS J-1 Visa Waiver Application Form 9/16/02 KANSAS PHYSICIAN/EMPLOYER REPORTING FORM Please submit upon commencement of practice and yearly thereafter. Physician: Name: (please print) Medical Practice Address: County Phone # I hereby declare and certify that I, the undersigned, have practiced Specialty medicine at the above-stated address a minimum of 40 hours per week since. Date: mo/day/year FINAL REPORT ONLY (expiration of contract): Signature I will will not (check one) remain in this position practice medicine. Date Employer: I hereby declare and certify that Dr. is employed by at the above-stated address and provides at least 40 hours of medicine per week. Specialty Signature Date Subscribed and sworn before me this day of, 200. Notary Public Page 17