NHSC Recruitment and Retention Assistance Application

INSTRUCTIONS FOR COMPLETING THE NHSC MULTI-YEAR RECRUITMENT AND RETENTION ASSISTANCE APPLICATION

The Bureau of Clinician Recruitment and Service (BCRS), National Health Service Corps (NHSC) Multi-year Recruitment and Retention Assistance Application (R&R)

Below, please find the instructions for completing the R&R application. A health care facility or its parent organization must submit an application for consideration to become a NHSC clinical practice site. Once approved, participating sites must submit an updated R&R application if there are changes to the parent organization, and/or health care delivery site(s) under the governance of the parent organization. Additionally, a new application is required when there are changes in the Health Professional Shortage Area (HPSA). Each approved application will remain in good standing for a period not to exceed three years. Sites may renew their eligibility by submitting a new R&R.

Please read the instructions carefully before completing the R&R Application. Each applicant (primary organization and/or satellite clinical practice site) should contact their respective State Primary Care Office (PCO) prior to submission to obtain pertinent HPSA and other information necessary to complete the R&R Application.

1. Practice Site Information: The following NHSC clinical practice site requirements are universally applied to all eligible health care facilities. Each health facility’s Administrator or their designee will be held responsible for ensuring all information reported on this application is true and accurate. If any application information is found to be fraudulent, the application will be deemed ineligible; all vacancies will be removed from the NHSC Opportunities List; and the applicant organization will not be permitted to participate in the NHSC for a period not to exceed one year.

1. Clinical practice site name (primary organization or satellite component if applicable) designated and alternate points of contact, addresses, direct telephone numbers, email addresses and web site address (if applicable) for the clinical practice site(s) WHERE THE NHSC-OBLIGATED CLINICIAN WILL PROVIDE SERVICES. There is space below to provide a mailing address if the site location is different from the Clinical practice site.

2. NHSC-obligated clinicians are NHSC Scholars or Loan Repayor who incur a contractual obligation to provide primary care services in an ambulatory (outpatient) care setting at NHSC-approved clinical practice sites. If the NHSC-obligated clinician will be practicing at more than one clinical practice site, EACH site must complete a R&R application and be approved for participation in the program(s). The projected clinical time spent at each location should be noted on each application as a percentage (example: 50% at Site 1; 50% at Site 2). NHSC-obligated clinicians may divide their services between a maximum of four NHSC-approved clinical practice sites.

3. All clinical practice sites, including satellite locations, must be approved by the NHSC before an NHSC-obligated clinician may begin work and receive obligated service credit. If the NHSC-obligated clinician begins his/her employment at any unapproved clinical practice site, the time served will NOT count toward their obligated service credit. Creditable service time may begin only after an eligible clinical practice site has been approved. The NHSC will provide written notification to the Health Care Administrator that an eligible clinical practice site has been approved.

2. Information About the Practice:

1. Type of Practice:

• Federally Qualified Health Center (FQHC) FQHCs include all organizations receiving federal grants under Section 330 of the Public Health Service Act. This Act defines federal grant funding opportunities for organizations to provide care to underserved populations. Types of organizations that may receive 330 grants include: Community Health Centers, Migrant Health Centers, Health Care for the Homeless Programs, and Public Housing Primary Care Programs. FQHCs are public or non-profit entities.

• Federally Qualified Health Center (FQHC) Look-Alike An FQHC Look-Alike is an organization that meets all of the eligibility requirements of an organization that receives a Public Health Service Section 330 grant (see above), but does not receive grant funding. FQHC Look-Alike sites are public or non-profit entities.

• Certified Rural Health Clinics (RHC) Public, private or non-profit private clinics located in rural shortage areas certified to receive special Medicare and Medicaid reimbursement. RHCs are required to use a team approach of physicians, nurse practitioners, physician assistants, and certified nurse midwives to provide services.

• Federal Indian Health Service (IHS) Clinic Provide comprehensive health services to Native Americans and Alaskan natives. Run by the Federal government through the Indian Health Service. The service models range dramatically from hospital and ambulatory clinics to health centers and satellite clinics.

• Tribally Run (638 Compacted/Self Governance) Indian Health Service Ambulatory Care Clinic Provide comprehensive health services to Native Americans and Alaskan natives. Run by the tribe(s). These sites must also agree to treat all members of the community, regardless of their tribal status or Native American background, in order to be eligible for NHSC clinicians.

• Solo Practice/Partnerships A solo practice or two-person practice can be organized as a practice that focuses on any one or combination of the following types of primary and preventive health care: primary medical, dental or mental health.

• Group Practices Range from three practitioners to hundreds. Group practices can be organized as entities on a fee-for-service basis, a capitation basis or a combination of the two. They can be family practice groups, primary care groups, or multi-specialty groups.

• Clinic Network Umbrella for groups of clinics; individual clinics are often managed by teams of practitioners and/or administrators where a central management structure exists; the central structure often provides computerized systems for accounting, billing and personnel management.

• Managed Care Includes organizations such as Health Maintenance Organizations (HMOs) or Individual Practice Associations (IPAs).

• Hospital Affiliated Primary Care Practice Often provided as part of a diversification program with services being provided onsite at the hospital or in hospital-sponsored satellite clinics located in inner city or rural communities.

• Public Health Departments Primary or mental health clinics operated by a State, County or Local health department.

• State, County or Local Prison System

• Federal Bureau of Prisons

• Department of Immigration Health Services (ICE)

3. Contact Information:

1. Parent Agency: Each parent/primary organization must provide the NHSC with its official, complete name and address.

2. Uniformed Data System (UDS) Number. Please provide the UDS number on your application. Any site that was approved previously as a NHSC clinical practice site or received funding from the Health Resources and Services Administration’s Bureau of Primary Health Care will have a UDS number. If you are not sure of the site’s UDS number, please contact your State Primary Care Office for assistance. If you are a Community Health Center, you also may contact the Bureau of Primary Health Care (BPHC) and speak to your Project Officer for assistance.

3. Human Resources/Recruitment Contact: List the designated NHSC point of contact and an alternate point of contact, to include their names and titles, direct telephone numbers, fax, and e-mail addresses of the individuals who will accept resumes and communications from potential recruits. IT IS CRITICAL THAT THIS INFORMATION BE ACCURATE, AS IT WILL APPEAR ON THE NHSC ON-LINE OPPORTUNITY LIST AS THE CONTACT PERSON FOR JOBS AT THE SITE.

4. Staffing Levels:

The number of NHSC-obligated clinicians who can be assigned to a NHSC-approved clinical practice site is limited. Please see the attached sheet entitled, “NHSC Update 2008/2009” for current NHSC-obligated clinician placement limits.

1. Enter the total number of NHSC vacancies requested by discipline and specialty. The NHSC can only approve full-time positions. Therefore, if a vacancy is split between 2 or more sites, all sites must be approved by the NHSC prior to the NHSC-obligated clinician joining the practice. Please indicate if the vacancy is a full time equivalent (FTE) or a percentage of FTE (i.e., 50%, 25%) and include the projected hire date. Additionally, each NHSC-approved clinical practice site is required to submit a position description for each NHSC clinician vacancy requested.

2. Please be as accurate as possible with projected hire dates. If your NHSC-approved site is not actively recruiting for positions (i.e., accepting resumes and scheduling interviews), please do not post vacancies at this time. Please request a vacancy only when your clinical practice site is ready to actively recruit for a position. You will not be required to complete another NHSC Multi-Year Recruitment and Retention Application when your recruitment needs change, as long as your clinical practice site remains in a HPSA and continues to meet ALL NHSC requirements.

3. If you are requesting a NHSC vacancy for a clinician currently employed at your clinical practice site, please indicate “filled” in the projected hire date column. Provide the clinician’s name and whether they are a NHSC Scholar or Loan Repayor in the next column.

4. If you are requesting a NHSC vacancy be filled by a United States Public Health Service Commissioned Officer, please type/write “YES” in the space provided. If that Commissioned Officer is also a Ready Responder, please type/write “RR” in the same space.

Please remember that ALL NHSC-obligated clinicians must be engaged in full-time primary care clinical practice, as defined in the application’s Agreement For All Participating NHSC Sites. This means that ALL NHSC obligated clinicians must provide direct (hands-on) primary care services in an ambulatory (outpatient) care setting. Please note that approval as an NHSC clinical practice site does not guarantee that the clinician you hire will be eligible for NHSC support and/or to serve at your site. All clinicians must individually apply to the NHSC and be approved for service. Please direct interested clinicians to 1-800-221-9393.

5. Agreement for All Participating NHSC Sites:

1. Enter the complete name and address of the clinical practice site(s) where the NHSC-obligated clinician will work (the location where direct primary care services will be provided.)

2. It is important that each eligible clinical practice site, primary and/or satellite, understands the requirements for becoming and remaining in good standing as an NHSC clinical site(s) as outlined in the application’s Agreement For All Participating NHSC Sites. All eligible clinical practice sites must meet all requirements in the Agreement AT THE TIME OF APPLICATION. Clinical practice sites cannot be approved unless all requirements are currently being met. Additionally, clinical practice sites must agree that, if approved, they will continue to meet the requirements until the NHSC-approval is terminated or the site terminates its participation in NHSC programs. Clinical practice sites must continue to meet all requirements as long as NHSC obligated clinicians are serving at the site. All approved NHSC clinical practice sites should expect a site visit while participating in the NHSC program to ensure adherence to all NHSC requirements. If there are any questions regarding any of the NHSC requirements listed in the Agreement, please contact the NHSC at 1-800-221-9393 for clarification before signing and submitting the NHSC R&R application. NHSC clinical practice site approval is good for three (3) years. Approved NHSC clinical practice sites must notify the NHSC of any change in site or NHSC clinician employment status.

6. Signature of Site Official and Date. Name, date, title and signature of the Approving Site Official. The Approving Site Official is the person with the authority to attest that the site agrees to abide by all NHSC requirements, as outlined in Section 5. Any false statement(s) herein may be punished as a felony under U.S. Code, Title 18, Section 1001 and subject the signer to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79).

7. Mail or fax the completed application to: NHSC/Site and Community Development Branch,

5600 Fishers Lane, Room 8A-55, Rockville, MD 20857; Fax# 301-594-2721. If you have any questions, please call the NHSC at 1-800-221-9393.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. The OMB control number for this project is 0915-0230. Public reporting burden for the applicant for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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