Fillable Delta Doctors Program J-1 Visa Waiver Application Checklist (Delta Regional Authority)

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Delta Doctors Program J-1 Visa Waiver Application Checklist (Delta Regional Authority)

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The Delta Doctors Program J-1 Visa Waiver Application Checklist (Delta Regional Authority) form is 6 pages long and contains:

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File type: PDF

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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
Attorney
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 Checklist (Delta Regional Authority)

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Completed 25 January 2021

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