Fillable Delta Doctors Program National Interest Waiver Review Checklist (Delta Regional Authority)

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Delta Doctors Program National Interest Waiver Review Checklist (Delta Regional Authority)

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The Delta Doctors Program National Interest Waiver Review Checklist (Delta Regional Authority) form is 3 pages long and contains:

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  • 20 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Delta Regional Authority

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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:
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
6
Complete passport (Verify all pages)
Summary of Reviewer’s Findings:
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Delta Doctors Program National Interest Waiver Review Checklist (Delta Regional Authority)

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Completed 25 January 2021

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