Site Application 2 by 7Hwfk9


                                   SITE APPLICATION
Application for determination of site eligibility in the Oregon Partnership State Loan Repayment Program for health care
          providers practicing in a Health Professional Shortage Area (HPSA), funded by community partners
                                           and the National Health Service Corps.

       APPLICATION DEADLINE: Applications accepted on an ongoing basis:
       (Facsimiles and electronic submissions accepted, if followed by a hard copy via postal delivery.)
       A Site Application must be submitted in conjunction with the Candidate Application for full
       Please type or print your responses.

       1.      Name of Practice:
               Street Address:
               City:                                        State:          Zip:              County:
               Phone Number:                                         Fax:
               U.S. Cong. District:      __________

       2.      Clinic Contact:                                                       Title:
               Phone Number:                                Fax:                     Email:

       3.      Name of Parent Organization:
               Street Address:
               City:                                                        State:            Zip:
               Executive Director’s Name:
               Phone Number:                                Fax:
               Email:            ______________

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4.      HPSA ID:                                                         Date of Designation:
        HPSA Name:                                                                  Score:
        (HPSA information available on the federal database at: )

5.      Type of Organization:                          Public                       Private Nonprofit
        (For-profits not eligible)                     CHC                          FQHC
                                                       Other, specify:

6.      Indicate the provider’s name for which loan repayment is being requested, degree, the
        projected start date, and if the provider is already on site.
        Name, Degree                                            Projected Start Date             On Site?
                                                                                                 Yes    No
        ____________________________________________            _________________                Yes    No
        ____________________________________________            _________________                Yes    No

7.      Please attach an explanation of the challenges your site experiences with the following
        issues and how participation in the Oregon Partnership State Loan Repayment Program
        may improve them. 1) Recruitment and retention of providers; 2) Barriers for patient
        access to care; 3) Health disparities of the patient population; and 4) Poor patient health

8.      Total number of patient encounters at site:
        Percentage of sliding fee patients:
        Percentage of Medicaid patients:
        Percentage of Medicare patients:
        Percentage of patients below 200% poverty:

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9.      ASSURANCES (Executive Director or legal representative must initial applicable
                A.    We do not discriminate in the provision of services to an individual (i)
               because the individual is unable to pay or because payment for those services would
               be made under Medicare, Medicaid or the State Children’s Health Insurance
               Program or (ii) based upon the individual’s race, color, gender, sexual orientation,
               national origin, disability or religion. (Please include a copy of these policies
               with the application.)

                B.     We use a schedule of fees or payments for the site’s services that is
               consistent with locally prevailing rates or charges and is designed to cover the site’s
               reasonable cost of operation.

                C.     We have a policy to accept all patients regardless of their ability to pay. The
               policy includes an implemented schedule of discounts (sliding fee scale) for patients
               whose income is under 200 percent of federal poverty guidelines. (Please include
               a copy of this policy with the application.)

                D.    We accept assignment for Medicare beneficiaries and have entered into an
               appropriate agreement with the applicable state agency for Medicaid and State
               Children’s Health Insurance Program beneficiaries.

                E.     We provide culturally appropriate ambulatory primary health, dental health,
               and/or mental health care services and function as part of a system of care which
               either offers or assures access to ancillary, inpatient, and specialty referrals.

                F.     We assure that funds are currently available to support the provider
               identified for loan repayment. This amount includes 50% of the provider’s loan
               repayment award for the minimum service obligation period of 2 years (midlevel
               provider) or 3 years (physician or dentist), plus 10% for administrative costs of the

                G.    We assure that the salaries for health professionals participating in the SLRP
               are based on prevailing rates in the area and that the SLRP contracts will not be
               used as a salary offset.

                H.     We are aware of the clinician requirements for the SLRP health
               professionals and will require participants to maintain a full-time primary care out-
               patient clinical practice.

                H.     We have a documented record of sound fiscal management.

                I.     We have a retention plan/strategy in place.

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10.     Level of support for this candidate from this site: $_______________

11.     Oregon Partnership State Loan Repayment Program contract start date:______________________

12.     Signature of Executive Director
        Name                                                                   Date

Please submit completed Site Application with a Candidate Application:

        Oregon Office of Rural Health, L593
        Oregon Health & Science University
        3181 SW Sam Jackson Park Road
        Portland, OR 97239

You may submit this form electronically by e-mailing it to, or faxing it to
503.494.4798. If you choose either of these options, the original hard copy form must be mailed
and received by the Oregon Office of Rural Health.

Questions about this program or application should be directed to Julie Hoffer, or

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