Internal Application Review Sheet Page 2
_____________ 1 Letter of Opinion from Legal Representation
______requesting NIW?
_____________ 2 G-28 with application fee of $ 3,000.00
_____________ 3 Cover Letter From Employer / Facility
NIW support
MUA No.
HPSA No.
FIPS No.
Physician Information
Medicare/Medicaid/Indigent-3yr. Data
Check Patient to Physician Ratio
_____________ 4 DRA J-1 Policy Document
Signed/dated by Physician/Employer
_____________ 5 DRA Affidavit and Agreement
Signed/dated/notarized by Physician
Verify all pages are included.
_____________ 6 DOS Data Sheet & DOS Case Number Sheet
2 copies
Verify DOS No. on website
_____________ 7 CV with SSN
_____________ 8 DOS Exchange Visitor Attestation Form
Signed/dated/notarized by Physician
_____________ 9 Copy of Executed Contract
Signed/dated by Physician/Employer
3 year service ______ 5 year (NIW)
No non-compete clause
40 hours per week of Primary Care
Service to Medicaid/Medicare/Indigent Patients
Base Salary is: __________
Name of facility and address
DRA Liquidated Damages Clause Included
_____________ 10 Proof of Prevailing Wage Data
Level I ___________ Level II __________
