Fillable Delta Doctors - Program Overview Packet (12.2020) (Delta Regional Authority)

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Delta Doctors - Program Overview Packet (12.2020) (Delta Regional Authority)

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DELTA DOCTORS
Delta Doctors Program – J-1 Visa Waiv
er Program Guidelines
Effective: September 4, 2020
J-1 Visa Waiver Program
Guidelines
The Delta Regional Authority (DRA) is committed to helping all residents of the Mississippi River
Delta Region have access to quality, affordable healthcare to strengthen economic development
across the eight-state region. Accordingly, DRA will consider recommending a waiver of the
foreign residence requirement on behalf of physicians holding J-1 Visas under certain conditions.
DRA’s policy is completely discretionary, voluntary, and may be modified or terminated at any
time without notice. In all instances, DRA reserves the right to recommend or decline any request
for a waiver. Furthermore, DRA reserves the right for periodic review and possible revision of the
program.
DRA encourages its member states to be involved in the agency’s J-1 Visa Waiver process because
state health agencies are familiar with local health provider shortage issues and opportunities.
DRA’s process offers states various opportunities for input in the request for the waiver so long as
the state agency provides feedback within the timeframe specified by DRA policy.
These guidelines are the requirements with which employers, immigration attorneys, and physician
applicants must comply for consideration of a J-1 Visa Waiver recommendation from DRA.
1. The employer’s first major prerequisite before requesting a J-1 visa waiver is to make a
good-faith effort to recruit an American physician for the opportunity in the same salary
range, without success, for a period of 45 days. Recruitment efforts must take place before
the employer offers employment to or engages in an employment contract with a physician
holding a J-1 visa and no longer than 12 months prior to the submission of the J-1 Visa
Waiver application.
DRA requires evidence of recruitment on three levels: national, in-state, and state medical
school recruitment.
All documentation of advertising and recruitment must be specifically targeted to the
employment opportunity (e.g., practice type, specific location, and specific employer).
Acceptable documentation shall include copies of advertisements for the position
published in newspapers, journals, copies of letters to state medical schools, targeted
mailings, and/or copies of on-line advertisements that specifically target the practice
opportunity. All documentation must include evidence of advertising duration.
Delta Doctors Program – J-1 Visa Waiv
er Program Guidelines
Effective: September 4, 2020
Examples of out-of-state publications which are acceptable include newspapers with
national circulation (such as USA Today or The Wall Street Journal) or medical journals
(such as JAMA or the New England Journal of Medicine).
Examples of in-state publications which are acceptable include newspapers with major in-
state circulation (such as The Commercial Appeal, The Arkansas Democrat Gazette, or The
Clarion Ledger), publications which are circulated in the practice area such as local
newspapers/magazines, or in-state medical journals or publications.
2. The physician must agree to provide primary medical care for not less than forty (40) hours
per week, or 160 hours per month, at a site in a Health Professional Shortage Area (HPSA),
Mental Health Professional Shortage Area (MHPSA), Medically Underserved Area
(MUA), or Medically Underserved Population (MUP) as designated by the Secretary of
the U.S.
Department of Health and Human Services, within the congressionally defined
DRA footprint for a minimum of three years or longer. Primary medical care is defined as
general or family practice, general internal medicine, pediatrics, obstetrics/gynecology and
psychiatry (MHPSA).
DRA may also make wavier recommendations for physicians who wish to practice
specialty medicine, given the following information is provided in addition to the
requirements for primary care medicine are met:
Ø A letter from the sponsor outlining the reasons a physician or an additional
physician with this particular specialty is needed in this area. The letter should
contain information describing the particular need for the specialist. The letter shall
also contain information concerning the impact of this service not being adequately
available to the area, the closest location where this specialty is available if not in
this area and whether public transportation is available, and evidence that a
physician of this specialty would be viable in the service area;
Ø A description of the service area demographics and any other information DRA
may use to determine exceptional need for the specialty;
Ø A letter of support from the Chief Medical Officer of the facility to which the J-1
physician would provide services to patients addressing the need for this specialty;
Ø At least two (2) letters of support from representatives of primary care centers and
primary care physician practices (not affiliated with the sponsor) in the area
addressing the need for this specialty; and
Ø Any additional evidence that would demonstrate the shortage and need for the
specialist, such as letters of support from other physicians of the same specialty or
local health officers in the service area.
3. The employment contract between the physician and the employer shall not contain a non-
compete clause or any other restrictive covenant enforceable against the foreign medical
graduate after the tenure of the contract period.
Delta Doctors Program – J-1 Visa Waiv
er Program Guidelines
Effective: September 4, 2020
4. The physician shall provide a copy of his or her state medical license or provide evidence
of the filing of a license application. A copy of the state medical license must be received
by DRA by the time the “Physician Employment Verification Form,” is filed in the first
week the physician begins work.
5. The physician shall provide DRA with copies of all of his or her Certificates of Eligibility
for Exchange Visitor (J-1) Status, forms IAP-66/DS-2019, and any other documentation
needed to verify status.
6. It is federal policy that the facility or practice sponsoring the physician must agree to
provide health services to individuals without discriminating against them because: (a) they
were unable to pay for those services or (b) payment for those health services will be made
under Medicare and Medicaid, or a state equivalent indigent health care program.
Furthermore, the facility should provide care on a sliding fee payment arrangement for
uninsured, low income patients and have this notice publicly posted in the facility.
Therefore, the application must include a statement, signed and dated by the head of the
healthcare facility at which the foreign medical graduate will be employed, addressing the
following:
Ø The facility is located in DRA’s congressionally-mandated footprint and designated
by the Secretary of the U.S. Department of Health and Human Services as a Health
Professional Shortage Area (HPSA), Mental Health Professional Shortage Area
(MHPSA), Medically Underserved Area (MUA), or Medically Underserved
Population (MUP), including the shortage designation identification number.
Ø The facility’s recent history serving Medicare, Medicaid and medically indigent
patients by providing patient data for the three most-recent years of service as well
as their continuing intentions to serve such individuals.
Ø The current patient-to-physician ratios in the practice area, which should be
described geographically and demographically in detail in the statement.
Ø The name of the physician, area of study, and how these skills will impact patients
at this facility.
7. The physician and employer must sign the DRA “J-1 Visa Waiver Program Guidelines.”
The physician must sign and have notarized the DRA “J-1 Visa Waiver Program Affidavit
and Agreement” prior to consideration by DRA of the request and must comply with the
terms and conditions set forth in those documents.
8. All requests approved initially by DRA and approved subsequently by the U.S. Citizenship
and Immigration Service will be subject to the periodic review by DRA for compliance
with this policy statement and other applicable laws. An employer’s failure to comply in
good faith with this waiver policy will be considered in the evaluation of other applications
involving the same employer.
9. DRA does not provide letters of support or no objection for any instances of change in
employment status since the agency cannot and does not determine extenuating
Delta Doctors Program – J-1 Visa Waiver Program Guidelines
Effective:
September 4, 2020
circumstances. On a case-by-case basis, DRA will consider providing letters of support for
previously-recommended physicians seeking to add another eligible healthcare facility to
their list of work sites.
10. If the employment contract specified in Section 2 provides for a minimum of
five years employment, DRA will accept a request for a National Interest
Waiver (NIW) support letter.
11. The J-1 physician shall submit a personal statement indicating the reasons for not wishing
to fulfill the two-year home country residence requirement to which the physician
agreed to at the time of accepting the exchange visitor status.
12. DRA’s J-1 Visa Waiver Application Package should include an application processing fee
in the amount of $3,000.00. This fee will be non-refundable. A partial refund request may
be submitted to DRA in writing if, and only if, the application is withdrawn within twenty
calendar days after DRA receives the application. If the request is
granted, only fifty percent of the application processing fee will be refunded.
Make check or money order payable to the Delta Regional Authority.
13. DRA will strive to use the respective states’ patient-to-physician ratio to place
physicians in those respective states. However, in special need situations, DRA
reserves the right to use a minimum patient-to-physician ratio of 2,000 to 1 to qualify
the physician for placement.
14. DRA does not expedite the review of J-1 Visa Waiver Application Packages. Please allow
at least 60 business days for processing.
I have read, fully understand, and comply with the policies and provisions set forth in this
document by the Delta Regional Authority
______________________________ ____________________
Physician’s Signature Date
______________________________ ____________________
Employer’s Signature Date
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Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
Delta Regional Authority
J-1 Visa Waiver Program
Affidavit and Agreement
I, ______________________________, being duly sworn, hereby request the Delta
Regional Authority (DRA) to review my application for the purpose of recommending a
waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant to 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 to grant my request, I hold harmless DRA, the Federal Co-
Chairman, any and all DRA employees and representatives from any action or lack of
action made in connection to this request.
2. I further understand and acknowledge that the entire basis for the consideration of my
request is DRA’s desire to improve the availability of primary and specialty medical care
in areas designated by the Secretary of the U.S. Department of Health and Human Services
as a Health Professional Shortage Area (HPSA), Mental Health Professional Shortage Area
(MHPSA), Medically Underserved Area (MUA), or Medically Underserved Population
(MUP) within DRA’s congressionally-mandated footprint. I understand DRA only
provides J-1 visa waiver recommendations for physicians practicing at work sites located
within DRA’s congressionally-designated footprint, and I agree to practice therein.
Furthermore, I understand the sponsorship of any waiver by DRA is strictly voluntarily.
3. I understand and agree that in consideration for a waiver, which eventually may or may not
be granted, I shall render primary or specialty medical care services to patients, including
the indigent, for a minimum of forty (40) hours per week, or 160 hours per month, within
a designated HPSA, MUA, MHPSA, or MUP located within DRA’s congressionally-
mandated footprint. Unless there are extenuating circumstances which DRA approves,
such service shall commence no later than 90 days after I receive approval by USCIS of
my waiver request and shall continue for a minimum of three years or longer in accordance
with the employment contract.
4. I understand and acknowledge that DRA does not provide letters of support or no objection
for any instances of change in employment status. DRA cannot and does not determine
extenuating circumstances.
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
5. I agree to incorporate all the terms of this “J-1 Visa Waiver Affidavit and Agreement” into
any and all employment agreements I enter pursuant to paragraph 3 and to include in each
such agreement DRA’s liquidated damages clause, which is attached hereto, payable to the
employer (a copy of all employment agreements are attached to this request). This damages
clause shall be activated by my termination of employment, initiated by my employer for
cause or by me for any reason, only if my termination occurs before fulfilling the minimum
three-year service requirement. In the event of a transfer under DRA’s liquidated damages
clause, a transfer notification form must be obtained by DRA. I will ensure that this form
is completed and returned to DRA with a copy to the State Contact.
6. I further agree that any employment agreement I enter pursuant to paragraph 3 shall not
contain any provision, which modifies or amends any of the terms of this “J-1 Visa Waiver
Affidavit and Agreement.”
7. I understand and agree that I will provide health services to individuals without
discriminating against them because: (a) they are unable to pay for those services or (b)
payment for those health services will be made under Medicare or Medicaid.
8. I have read, signed, and fully understand the “DRA J-1 Visa Waiver Program Guidelines”,
a copy of which is attached to this request.
9. I expressly understand this waiver of my foreign residence requirement must ultimately be
approved by the USCIS, and I agree to provide placement notification of the specific
location and nature of my practice to DRA when I commence rendering services within
DRA’s congressionally-mandated footprint.
10. I declare and certify, under penalty of the provisions of 18 U.S.C. 1101, that I do not have
pending nor am I submitting during the pendency of this request, another request to any
United States Government department or agency or any State Department of Public Health,
or equivalent, other than DRA to act on my behalf in any matter relating to a waiver of my
two-year home-country physical presence requirement.
11. I understand and acknowledge that if I willfully fail to comply with the terms of this “J-1
Visa Waiver Affidavit and Agreement,” DRA’s Office of the Federal Co-Chairman will
notify the USCIS that I am out of compliance. Additionally, any and all other measures
available to the Office of the Federal Co-Chairman will be executed in the event of my
non-compliance.
LIQUIDATED DAMAGES CLAUSE
Any breach or non-fulfillment of conditions will be considered a substantial breach of this
agreement by you. If there is such a breach ________________________________________
(Employer) may, at its option, terminate this agreement immediately. In addition, it is agreed that
____________________________________ (Employer) will be substantially damaged by your
failure to remain at _____________________________________ (Employer/Facility Name) in
the practice of medicine for a minimum of three years and that, considering that precise damaged
are difficult to calculate, you will agree to pay _________________________________
(Employer) the sum of $250,000.00 if you fail to fulfill any portion of your minimum three-year
contract. Should you perform any portion of the employment contract, you agree to pay a pro rata
share based upon the number of months you failed to fulfill (i.e. $6,945.00 per month). In addition
to liquidated damages, ________________________________ (Employer) will recover from you
any other consequential damages, and reasonable attorney fees costs and expenses, due to the
failure to provide services to ____________________________________ (Employer) for a
minimum of three years, EXCEPT THAT, the full-time practice of medicine at another licensed
medical facility, in Health Professional Shortage area (as defined by the United States Public
Health Service) with the Delta Regional Authority (as defined by DRA) shall be considered the
same a fulltime practice of medicine at _______________________________________
(Employer) for purpose of this paragraph. In the event of a dispute under this paragraph, either
party may submit this matter to binding arbitration.
The parties agree in consideration of compliance with the forgoing, to indemnify and hold harmless
the Delta Regional Authority and / or any person, firm or corporation now or hereafter acting as
agent for the DRA in any capacity, and any successors in any such capacities and successors and
assigns of DRA, from and against any loss, claim, damage and expense in connection with, or
arising out of, compliance with the waiver application set forth herein or any other litigation.
Re: Additional Liquidated Damages Clauses
Any other clause mandating consequential or liquidated damages being paid to the employer must
be separate for the DRA clause. DRA takes no position with respect to the inclusion of such an
additional contractual agreement.
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
I declare under the penalties of perjury that the foregoing is true and correct.
Physician’s Signature: _________________________________________
Physician’s Name: ____________________________________________
Subscribed and sworn before me this ______ day of ______________________, 20_____.
__________________________________________ (Notary Public)
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DRA Delta Doctors Program – Waiver of Liquidated Damages Clause Requirement
Effective: September 4, 2020
Delta Doctors Program
Waiver of Liquidated Damages Clause Requirement
__________________________ (Employer) and ___________________________
(Physician) hereby agree to waive the Liquidated Damages Clause required by Delta
Regional Authority (DRA) as set forth in the Delta Regional Authority J-1
Visa Waiver Program Affidavit and Agreement.
DRA takes no position with respect to the inclusion of any other clause mandating
consequential or liquidated damages being paid to the employer.
_____________________________ ______________________________
Physician’s Signature Employer’s Signature
_
____________________________ ______________________________
Date Date
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
Delta Doctors Program
J-1 Visa Waiver Application Checklist
Name of reviewer: Physician’s name:
Date received: DOS case number:
Review process start date: DOB:
Copy of check: Country of origin:
Date sent to DOS: Specialty:
Tracking number: Current address:
Copy of DRA’s letter:
Copy of shipping receipt: Phone number:
Sent attorney DRA letter: Email:
Recorded in database: HPSA number:
Reviewer notes: MUA number:
Term:
Work site:
*Provide additional
worksites with
HPSA/MUA number(s)
on separate page.
County/Parish:
Attorney: Employer name:
Firm name: Employer contact name:
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
A
ttorney address:
E
mployer address:
Attorney phone number: Employer phone number:
Attorney fax number: Employer fax number:
Attorney email: Employer email:
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
Delta Doctors Program
J-1 Visa Waiver Application Checklist
Two packets are required for submission to the Delta Regional Authority.
Packet 1: Must contain Items 1 through 9.
Packet 2: Must contain Items 1 through 27.
Checklist
For DRA use
only.
Item
#
Required Documentation/Information
Checklist
1 G-28
2 Cover letter from employer/facility
NIW support?
HPSA number:
MUA number:
FIPS number:
Physician information
Medicare/Medicaid/Indigenous pop. (3-year data)
Patient-to-Physician ratio:
3 DOS data sheet and case number sheet
2 copies?
Case number verified?
4 CV with social Security number
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
5 DOS exchange visitor attestation form
Signed/Dated by physician; Notarized?
6 Copy of executed contract
Signed/Dated by physician and employer
3-year service? 5-year service (NIW)?
No non-compete clause
160 hours/month of primary/specialty medical care
Service to Medicare/Medicaid/Indigenous pop.
Base salary:
Name and address of each facility:
7 Proof of HPSA/MUA status
Status verified?
8 IAP-66/DS-2019
Verify from entry to present
9 Copy of I-94
10 Letter of opinion from legal representation
Requesting NIW?
11 DRA J-1 program guidelines
Signed/Dated by physician and employer
12 DRA affidavit and agreement
Signed/Dated by physician; Notarized?
All pages included?
13 Proof of prevailing wage data
Level I:
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
Level II:
14 Recruiting documentation
Recruitment overview
National/State/State Medical Schools/Other
15 Letters of community support
Two (2) local, unaffiliatd physicians
One (1) local elected official
16 Letters of recommendation
17 Copy of diploma(s), board certification(s), USLME scores, etc..
State medical license or application for license
18 Proof of existence for each facility
19 Copy of posted public notice of sliding fee payment for each facility
20 List of primary care or specialty physicians in county/parish
21 Passport(s)
22 Physician statement
NIW statement (if applicable)
If applicable (i.e. specialty physician):
23 Sponsor’s letter
24 Service area description
25 Letter of support – chief medical officer
26
Letters of support – Two (2) local, unaffilitated primary care physicians,
1 local elected official
27 Optional: Additional information to support specialty waiver
Delta Doctors Program – J-1 Visa Waiver Checklist
Effective: September 4, 2020
Summary of Reviewer’s Findings:
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Delta Doctors Program – J-1 Visa Waiver Application Requirements
Effective: September 4, 2020
J-1 Visa Waiver Program
Application Requirements
Each J-1 Visa waiver application packet must contain the items listed within the DRA checklist.
If documentation required in the checklist is omitted or does not meet the "Delta Doctors"
Program Guidelines, the application will be mailed back to the attorney and will be placed in the
back of the current applications that are in the DRA queue for review. The DRA checklist should
be completed and included in the J-1 visa waiver application to the Authority.
Send the original application and one copy directly to Delta Regional Authority.
Place the U.S. Department of State Case Number on all pages.
Tab the
application by the numbers listed below in the following order.
Please send the application processing fee (check or money order) of $3,000.00, payable to Delta
Regional Authority, to:
Delta Regional Authority
Attn: Kemp Morgan
236 Sharkey Avenue, Suite 400
Clarksdale, MS 38614
1. Letter of Opinion from Legal Representation
The attorney submitting the J-1 Visa waiver application should submit a letter of opinion
to the Delta Regional Authority simply stating that to the best of their knowledge the
information in the application is truthful, and that he / she believes the applicant is eligible
for the J-1 visa waiver and an ensuing H-1B visa. The letter shall further state that to the
best of their knowledge the facility in the application has followed all rules and
regulations outlined by the Delta Regional Authority policy to request a J-1 Visa Waiver
for a physician the facility wishes to employ.
2. G-28
3. Cover letter
The employer shall submit a cover letter with original signature, on the facility’s
letterhead. The cover letter should be addressed to the Delta Regional Authority and state
Delta Doctors Program – J-1 Visa Waiver Application Requirements
Effective: September 4, 2020
the facility is in a designated shortage area, provide the shortage area identifier number,
and the Federal Information Processing Standards (FIPS) county code and census tract or
block numbering area, and physical address for each worksite. The cover letter should
also include patient data for the facility to include numbers and percentages of Medicaid,
Medicare, and Uninsured patients served for the past three years. The cover letter should
also outline details from the sponsor specifically outlining what services the physician
will provide to the citizens in the facility’s service area and how their training will impact
the patients in this service area. Furthermore, this letter also must contain current patient
to physician ratios in the practice area.
4. DRA’s J-1 Policy Guidelines
(Signed and dated by employer and physician; original signatures required.)
5. J-1 Affidavit and Agreement
(Signed and notarized by the physician. Include all Pages of Document)
6. Department of State Data Sheet and Department of State Case Number
(2 copies of each) (Applicant must have Case Number prior to submitting application.)
7. Curriculum Vitae, including Social Security Number
8. Notarized Department of State Exchange Visitor Attestation Form
9. Copy of executed employment contract. The employment contract should include:
a. Name and address of each worksite
b. 3-year service term commitment
c. 40 hours per week or 160 hours per month of direct patient care
d. Base salary amount
e. No non-compete clause beyond the service term
f. Language regarding care to patients utilizing Medicare, Medicaid, and indigent
patients
g. Employer and employee signature and date
10. Proof of Prevailing Wage Data
(From the U.S. Department of Labor indicating the Level I and Level II wage for the
position in the practice area.)
11. Documentation of employer’s regional and national recruitment efforts
Include a recruitment overview letter from the employer outlining the recruitment efforts
and responses to advertisements placed for physicians. This letter should include
recruitment duration dates, forms and kind of recruiting done, and responses received
from those recruitment efforts.
Delta Doctors Program – J-1 Visa Waiver Application Requirements
Effective: September 4, 2020
As stated in the DRA J-1 Visa Waiver Program Guidelines, advertisements should be
conducted at three levels:
a. in publications which are national in scope,
b. in-state publications, and
c. written notifications to the respective state’s medical schools.
Documentation should include copies of advertisements for this job published in
newspapers, journals, state medical schools, mail-outs, etc., and other supporting
documentation which demonstrates good faith efforts in giving American physicians an
opportunity to apply.
Examples of out-of-state publications which are acceptable include newspapers with
national circulation (such as the USA Today or The Wall Street Journal) or medical
journals (such as JAMA or the New England Journal of Medicine).
Examples of in-state publications which are acceptable include newspapers with major
in-state circulation (such as The Commercial Appeal, The Arkansas Democrat Gazette, or
The Clarion Ledger), publications which are circulated in the practice area such as local
newspapers/magazines, or in-state medical journal or publications.
12. Proof of current HPSA, MUA, MUP or MHPS
A designation for community by worksite address.
13. Letters of community support (For Primary Care Physicians Only)
The application must include at least three letters of support. A minimum of two letters
must be provided by practicing physicians in the area who are permanent residents or
U.S. citizens and are not affiliated with the sponsor or worksite. The other letter(s) may
come from community leaders or local elected officials. Letters shall be addressed to the
Federal Co-Chairman of the Delta Regional Authority. No form letters.
14. Letters of recommendation
Letters may come from those who know the J-1 physician’s qualifications, such as
medical directors who oversaw the physician’s residency training. Letters shall be
addressed to the Federal Co-Chairman of the Delta Regional Authority. No form letters.
15. Copies of physician’s diplomas, licenses, board certifications, USMLE scores, etc.
16. Current proof of existence for each facility
(Facilities must provide proof of existence such as business license, occupancy permit,
phonebook listing, or website information.)
17. Copy of facility’s posted public notice of sliding fee payment arrangement
18. List of all physicians in the county/parish serving in the same capacity as the J-1 visa
waiver applicant
Delta Doctors Program – J-1 Visa Waiver Application Requirements
Effective: September 4, 2020
19. Copy of complete passport
(Including all blank pages)
20. Readable copies of J-1’s IAP-66/DS-2019 forms
(For entire period in J-1 Status; from entry to present.)
21. Copy of Form I-94
(Front and back)
22. Physician Statement
A personal statement from the physician stating the reasons for not wishing to fulfill the
two-year country residence requirement to which the physician agreed to at the time of
accepting the exchange visitor status. The statement should further include the
physician’s reasons for practicing in this particular field of medicine, how their expertise
could impact the patients in the locality, and the reasons for accepting the employment
contract with the facility in the application.
If the physician is requesting a waiver to practice specialty medicine, the following
information (items 23-28) must be provided in addition to items 1-22.
23. Sponsor’s Letter
A letter from the sponsor outlining the reasons a physician or an additional physician
with this particular specialty is needed in this area. The letter shall also contain
information concerning the impact of this service not being adequately available to the
area, the closest location where this specialty is available if not in this area, whether
public transportation is available, and evidence that a physician of this specialty would be
viable in the service area.
24. Service Area Description
A description of the service area demographics and any other information the DRA may
use to determine exceptional need for the specialty. Reliable service area descriptions
include information from community assessment surveys, the U.S. Census Bureau, and
other reputable agencies. Wikipedia is not considered a reliable source.
25. Chief Medical Officer Letter of Support
A letter of support from the Chief Medical Officer of the facility to which the J-1
Physician would provide services to patients speaking to the need for this specialty.
26. Letters of Support
The application must include at least three letters of support. At least two (2) letters of
support from representatives of primary care centers and primary care physician practices
(not affiliated with the sponsor or the worksite) in the area speaking to the need for this
specialty. The other letter may come from community leaders or local elected officials.
No form letters.
27. Additional Information to Support Specialty Waiver Request
Any additional evidence that would tend to show the shortage and need for the specialist,
Delta Doctors Program – J-1 Visa Waiver Application Requirements
Effective: September 4, 2020
such as letters of support from other physicians of the same specialty or local health
officers in the service area.
Application Timeline
• Applicants must submit the original J-1 Visa Waiver application packet with one copy to
the Delta Regional Authority.
• DRA will make a recommendation on the J-1 Visa Waiver application within 60 days of
the receipt of a complete application. If approved, the DRA will forward the application
to the U.S. Department of State. The time period may be extended to allow for additional
investigation.
• DRA does not expedite the review of applications.
Delta Doctors Program – Physician Attestation Form
Effective: September 4, 2020
U.S. Department of State
Exchange Visitor Attestation
I, ________________________________________, hereby declare and certify, under penalty of
the provisions of 18 U.S.C. 1001, that I do not now have pending, nor am I submitting during the
pendency of this request, another request to any U.S. Government department or agency or any
other State Department of Public Health, or any equivalent, other than the Delta Regional
Authority, to act on my behalf in any matter relating to a waiver of my two-year home-country
physical-presence requirement.
__________________________________________ _____________________
Signature Date
Subscribed and sworn to before me This _________________________ day of _______, 20___.
__________________________________________
Notary Public
Delta Doctors Program – J-1 Visa Waiver Compliance Guidelines
Effective: September 4, 2020
J-1 Visa Waiver Program
Compliance Guidelines
The Delta Regional Authority will administer compliance of the J-1 Visa Waiver Program in
three steps:
1. The administrator of the facility and the physician will sign and return the “Physician
Employment Verification Form”, within the first week that the physician begins work.
Include copies of documentation that physician is in H-1B status including approval
notices from USCIS, the physician's I-94 forms and a copy of the H-1B visa stamp from
the physician's passport if the physician has already been granted an H-1B visa. If the
physician was not licensed in the state of practice at the time the application for the
waiver was submitted, a copy of the physician’s state medical license must be included
with this form.
2. Compliance Surveys are due on June 30
th
and December 31
st
of each year. The surveys
will be completed and returned separately to the DRA by both the J-1 physician and the
administrator of the facility. The surveys are not identical and will ask confidential
questions to both the J-1 physician and the administrator. This survey also requests the
number of Medicare, Medicaid, and indigent patients that the facility and the physician
has treated in that six-month period, and whether both parties have otherwise complied
with the terms of the DRA J-1 Visa Waiver Program.
The DRA has established formal deadlines for these surveys. Both surveys should be
returned to the DRA within 15 business days from the due date. If both surveys are not
returned within the initial 15 business days, the DRA will notify the employer that the
survey(s) should be returned within an extension period of 15 business days. If the
surveys are not returned within the extension period and if the employer has made no
effort or attempt to comply with DRA Compliance Guidelines, DRA will notify the
appropriate agencies that compliance efforts were unsuccessful and recommend the
taking of appropriate enforcement actions.
3. The DRA or an agent representing the DRA will conduct unannounced site visits at
random during the three-year employment period. If the physician or employer is found
to be out of compliance, the DRA will immediately notify the appropriate agencies and
recommend the taking of appropriate enforcement actions.
J-1 V
isa Waiver Program
Physician Employment Verification Form
Ø This form is not to be submitted with the waiver application, but is to be completed
and mailed to the DRA within the physician’s first week of practice.
Ø Include copies of the physician’s state medical license with this form if they were not
included / available at the time the J-1 Waiver Application was submitted. Also
include copies of I-94 renewals and approval notices with this document.
Ø If the physician will be providing services for the employer at different sites than the
office site listed below, please provide those addresses on a separate page and attach
to this form.
PHYSICIAN:
Name: (print or type)______________________________ Employment Start Date:_____________
I-612 Approval Date: ____________________ H-1(b) Approval Date: ____________________
Address: Home: ______________________________ Office: ___________________________
Street Street
______________________________ ___________________________
City/State/Zip City/State/Zip
______________________________ ___________________________
Home Phone Work Phone
Physician’s E-mail Address: _____________
__________________________________________
I hereby certify that I, the undersigned, do provide primary health care services at the above stated address
for a minimum of 40 hours per week or 160 hours per month.
Physician’s Signature_______________________________________ Date:_________________
DRA J-1 Visa Waiver Program – Physician Employment Verification Form
Effective: September 4, 2020
22
DRA J-1 Visa Waiver Program – Physician Employment Verification Form
Effective: September 4, 2020
EMPLOYER:
Name of Employer: _____________________________________________________________
Address: ______________________________ City/State/Zip: __________________________
County: _______________________________
Type of Medical Practice: _________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
Point of Contact Name: ___________________________________________________________
Phone Number: ___________________________ Email: _______________________________
I do hereby certify that Doctor ______________________________________________ is employed by
_______________________________________________________________________ and provides 40
hours of direct patient care per week, or 160 hours per month, at the above stated address.
____________________________________________
Employer’s Signature
____________________________________________
Employer’s Printed Name
____________________________________________
Date
DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
J-1 Visa Waiver Program
Physician Compliance Survey Part A (Employer)
Note: Responses to the questions listed on page two and three are strictly confidential. Only
designated staff with the Delta Regional Authority will view the responses to those questions.
Year: ________________________ Survey Number: _____________________
Survey Period: _________________ Survey Date: _______________________
Name
of Physician: _________________________________________________________
I-612 Approval Date: ____________________________
H-1(b) Approval Date: ___________________________
Employment Start Date: __________________________
Name of Employer: _____________________________________________________________
Point of Contact: _______________________________________________________________
Phone Number: ___________________________________________
E-mail Address: ___________________________________________
Name of Worksite (Please provide data for each worksite): _____________________________________
Type of Medical Practice: _______________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
Worksite Address: _____________________________________________________________________
Street/Location City/State/Zip County
Please indicate the number of patients that the facility has treated in the past six months.
Total No.
of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: _______________
No. of Medicare Patients: _________________ % of Total Patients: _______________
0.00%
0.00%
DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
Please indicate the number of patients that the physician has seen in the past six months.
Total No. of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: _________________
No. of Medicare Patients: _________________ %of Total Patients: _________________
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
I do hereby certify that Doctor ___________________________________________________ is
employed by ___________________________________________________________________
and provides 40 hours of direct patient care per week, or 160 hours per month.
___________________________ __________________________ ___________________
Employer’s Signature Employer’s Name and Title Date
Please answer the following questions in accordance with the indicated scale:
4=Excellent, 3=Good, 2=Average, 1=Poor
1. How would you rate your overall experience with the physician described above thus far?
_________________
2. How would you rate the way the physician has followed the terms set forth in the employment
contract? _________________
3. How would you rate the physician’s ability to communicate effectively with other physicians,
nurses, patients, etc.? ______________
4. How would you rate the way the physician has been accepted by patients at your medical facility?
________________
5. How would you rate the way the physician has been welcomed by the local community?
________________
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
Please
use the space provided below to make any positive statement or comment on any problem or
concern that you have in regard to the physician described above.
Please Return Form To:
Delta Regional Authority
Attention: Delta Doctors Program
236 Sharkey Avenue, Suite 400
Clarksdale, MS 38614
DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: Sep
tember 4, 2020
J-1 V
isa Waiver Program
Physician Compliance Survey Part B (Physician)
Note: Responses to the questions listed on page two and three are strictly confidential. Only
designated staff with the Delta Regional Authority will view the responses to those questions.
Year
: _________________________ Survey Number: ________________
Survey Period: __________________ Survey
Date: ___________________
Name: (print or type)______________________________
Empl
oyment Start Date: _____________________
I-612 Approval Date: _______________________
H-1(b) Approval Date: ______________________
Address: Home: _________________________________ Office:______________________________
Street Street
_________________________________ ______________________________
City/State/Zip City/State/Zip
_________________________________ ______________________________
Home Phone Work Phone
Physician’s E-mail Address: _____________________________________________________________
Name of Worksite (Please provide data for each worksite): _____________________________________
Worksite Address: _____________________________________________________________________
Street/Location City/State/Zip County
Type of Medical Practice: _______________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: September 4, 2020
Please indicate the number of patients that you have seen in the past six months.
Tota
l No. of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: ________________
No. of Medicare Patients: _________________ %of Total Patients: _________________
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
Please indicate the number of patients that the facility has treated in the past six months.
Tota
l No. of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: _________________
No. of Medicare Patients: _________________ %of Total Patients: _________________
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
I hereby certify that I, the undersigned, do provide direct patient care at the above stated worksite(s) for 40
hours per week, or 160 hours per month. I further attest that the information above is truthful and accurate.
Physician’s Signature_______________________________________ Date:_________________
Please answer the following questions in accordance with the indicated scale:
4=Excell
ent, 3=Good, 2=Average, 1=Poor
1. How would you rate your overall experience with the medical facility described above thus far?
_________________
2. How would you rate the way the administrator(s) of the medical facility has followed the terms set
forth in the employment contract? _________________
3. How would you rate the way that you have been treated by the administrator(s) of the medical
facility described above? ____________________
4. How would you rate the way you have been accepted by patients at the medical facility described
above? ________________
5. How would you rate the way you have been welcomed by the local community?
______________
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: Sep
tember 4, 2020
Please use the space provided to make any positive statement or comment on any problem or
concern that you have in regard to the medical facility listed above.
Please Return Form To:
Delta Regional Authority
Attention: Delta Doctors Program
236 Sharkey Avenue, Suite 400
Clarksdale, MS 38614
DRA Delta Doctors Program - Compliance Closing Survey
Effective: September 4, 2020
Delta Doctors Program
Physician Compliance Closing Survey
Note: Responses to the questions on this survey are strictly confidential. Only designated staff with
the Delta Regional Authority will view the responses to the following questions.
Date: ____________________________
Name: (print or type) __________________________________________________
Years Served: _____________ Employment Start Date:_______________
Address: Home:______________________________ Office:___________________________
Street Street
______________________________ ___________________________
City/State/Zip City/State/Zip
______________________________ ___________________________
Home Phone Work Phone
Physician’s E-mail Address: ______________________________________________________________
Name of Employer: _____________________________________________________________________
Address: ______________________________________________________________________
Street/Location City/State/Zip County
Type of Medical Practice: ________________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
I hereby certify that I, the undersigned, provided direct patient care for the above listed employer for 40
hours per week, or 160 hours per month, at a worksite(s) located within a HPSA or MUA. I further attest
that the information above is truthful and accurate.
I hereby acknowledge that all information and statements contained herein are true and do not misrepresent
facts, per requirements of 18 USC 1001 (Title 18, U.S. Code, Part 1, Chapter 47, Section 1001). I further
acknowledge that I have not evaded or suppressed any information contained in this document or in any of
the supporting materials.
Physician’s Signature: __________________________________________________
Date: __________________________________________________
DRA Delta Doctors Program - Compliance Closing Survey
Effective: September 4, 2020
Please answer the following questions:
1. Rate your overall experience with the Delta Doctors program:
Excellent Good Average Poor
2. Please list any suggestions you may have to improve the experience of the program?
3. Please list any suggestions you have that would have improved your work experience?
4. After your contracted term is complete, do you plan to continue working at the facility?
5. If not, where do you plan to locate and work next?
6. Would you to continue to practice medicine? If so, what type of medicine would you
practice?
7. Please list the reasons why you are leaving your current location.
8. Please list the reasons that would remain at your current location. (higher salary, becoming
a partner in the facility, better community experience, etc.)
DRA Delta Doctors Program - Compliance Closing Survey
Effective: September 4, 2020
Please use the space below to make any positive statement or comment on any problem or concern
that you have in regard to your overall experience with the Delta Doctors program:
Please Return Form to:
Delta Regional Authority
Attention: Delta Doctors Program
236 Sharkey Avenue, Suite 400
Clarksdale, MS 38614
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DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
J-1 Visa Waiver Program
Completion Request Form
Physician’s Name:________________________________________________________
Current Home Address:
Street:______________________________________________________
City: ___________________ State:___________ Zip Code:_________
Home Phone: ________________________________________________
Email Address: _______________________________________________
Employer’s Name: ________________________________________________________
Street:_______________________________________________________
City: ___________________ State:___________ Zip Code:__________
Phone: ______________________________________________________
Email Address: _______________________________________________
Point of Contact: ______________________________________________
Worksite(s): Please list additional worksites on Page 3:
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
I HEREBY CERTIFY THAT I, _____________________________________________,
PROVIDED DIRECT PATIENT CARE AT THE WORKSITE(S) LISTED FOR FORTY
(40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER MONTH,
FOR THREE (3) YEARS.
Physician’s Signature: ___________________________________
Date: _________________________________________________
I HEREBY CERTFIY THAT DOCTOR ____________________________________
PROVIDED DIRECT PARTIENT CARE AT THE WORKSITE(S) LISTED FOR
FORTY (40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER
MONTH, FOR THREE (3) YEARS.
Employer’s Signature: ___________________________________
Date: _________________________________________________
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DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
ADDITIONAL WORKSITES
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
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Delta Doctors Program – NIW Checklist
Effective:
September 4, 2020
Delta Doctors Program
National Interest Waiver Review Checklist
Process Start Date:
Date Received:
Reviewer Date:
Copy of FCC’s Letter File:
Copy of Shipping Receipt:
Emailed Attorney Letter:
Tracking Number:
Physician’s Name:
DOS Case Number:
DOB:
Current Address:
Country of Origin:
Specialty:
Worksite Name & Address:
MUA Number:
____________
Delta Doctors Program – NIW Check
list
Effective: September 4, 2020
HPSA Number:
County/Parish:
*Provide additional worksites with MUA/HPSA numbers on a separate page.
Attorney:
Firm Name:
Attorney Address:
Attorney Phone Number:
Attorney Fax Number:
Attorney Email:
Employer’s Name:
Employer Contact:
Employer’s Address:
Employer Phone Number:
Employer Fax Number:
Employer Email:
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signature
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Delta Doctors Program – NIW Check
list
Effective: September 4, 2020
1
2
3
4
Letter of Opinion from Legal Representatives
Form G-28
Physician Statement
Copy of Executed Contract
Signed/dated by Physician/Employer
5 Year (NIW)
40 Hours per week or 160 hours per month of direct
patient care
Service to Medicaid/Meidcare/Indigent Patients
Base Salary: ___________________________________
Name of each worksite and address
5
Copies of Diplomas, licenses or applications for licenses
State medical license or applicaton for license
USMLE Scores
6
Complete passport (Verify all pages)
I-129 Immigration Petition Approval Notice
H-1B Approval Notices
Copy of I-94
Summary of Reviewer’s Findings:
Delta Doctors Program – NIW Letter of Support Requirements
Effective: September 4, 2020
J-1 Visa Waiver Program
National Interest Waiver Letter of Support Requirements
Each national interest waiver packet must contain the items listed within the DRA checklist.
If documentation required in the checklist is omitted or does not meet the "Delta Doctors"
Program Guidelines, the application will be mailed back to the attorney and will be placed in the
back of the current applications that are in the DRA queue for review. The DRA checklist should
be completed and included in the J-1 visa waiver application to the Authority.
Send the original application and one copy directly to Delta Regional Authority.
Place the U.S. Department of State Case Number on all pages.
Tab the application by the numbers listed below in the following order.
DRA will make a decision on issuing a support letter upon receipt and review of the following:
Documents required for NIW support letter requested in conjunction with a J-1 waiver:
1. An executed employment contract between the physician and his/her employer, which commits
the physician to five years of service in a DRA underserved county or parish.
2. A statement from the physician’s employer committing support for the physician’s NIW, which
should be in the Employer Cover Letter.
3. A short testimonial from the physician expressing his/her reason for pursuing an NIW, which
should be expressed in the physician
statement.
4. A letter of opinion from a legal counsel stating “to the best of their knowledge, the information
in the application is truthful, and that he/she believes the applicant is eligible for a NIW”; this
should be stated in the original letter of opinion.
Delta Doctors Program – NIW Letter of Support Requirements
Effective: September 4, 2020
Documents required for NIW support letter requested after waiver has been granted:
1. An executed employment contract between the physician and his/her employer which commits
the physician to two or more additional years of service in a DRA underserved county or parish.
Self-employed physicians must present an affidavit committing him/her to two or more
additional years of service.
2. A statement from the physician’s employer committing support for the physician’s NIW.
3. A short testimonial from the physician expressing his/her reason for pursuing an NIW.
4. A letter of opinion from a legal counsel stating “to the best of their knowledge the information in
the application is truthful, and that he/she believes the applicant is eligible for a NIW.”
5. Copies of diplomas, licenses, board certifications, and USMLE scores.
6. A copy of the physician’s complete passport, I-129 Immigrant petition, H-1B approval notices
and I-94.
7. A copy of Form G-28
Regional Headquarters:
236 Sharkey Avenue, Suite 400 | Clarksdale, MS 38614
T 662.624.8600 | www.dra.gov
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Delta Doctors - Program Overview Packet (12.2020) (Delta Regional Authority)

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Completed 25 January 2021

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