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Fillable Printable Doh-5062 Dany Application Master Jul 02 2015

Fillable Printable Doh-5062 Dany Application Master Jul 02 2015

Doh-5062 Dany Application Master Jul 02 2015

Doh-5062 Dany Application Master Jul 02 2015

Physician Practice Support (PPS)
Physician Loan Repayment Program (PLR)
Select the program you are applying for (Check only ONE):
1. Applicant Name
Period of Service Obligation:
2. Applicant Address
3. Applicant’s FEIN (facilities only)
5. Person Completing this Application (Name & Title)
4. NYSDOH Operating Certificate # (if applicable)
Email
Name & Title
Signature
Phone
6. Name, title, and signature of individual authorized to attest to the accuracy of the information in this application and to bind the applicant to any contract
resulting from this application:
Section A. Applicant Information
Application to DANY
7. Applicant is
8. Applicant Type (Check one category and appropriate region).
For Profit (including Individual physicians)
Hospital or – Hospital Based Clinic
New York CityRest of State
New York CityRest of State
New York CityRest of State
New York CityRest of State
Diagnostic & Treatment CenterNew York CityRest of State
Other health care facility
Group medical practice
Individual physician
Not for Profit
New York CityRest of StateNYS OMH facility
NEW YORK STATE DEPARTMENT OF HEALTH
Doctors Across New York (DANY) - Physician Practice Support and Physician Loan Repayment Program
DOH-5062 (6/15) Page 1 of 6
Before completing this form, please read the instructions for completing the application at the following website:
//www.health.ny.gov/professionals/doctors/graduate_medical_education/doctors_across_ny/
All applications must be submitted electronically to the New York State Department of Health by July 31, 2015, in PDF format only to gme@health.ny.gov
fromto
4. Email3. Phone
1. Physician Name
2. Physician Address
Section B. Physician Information
DOH-5062 (6/15) Page 2 of 6
5. A physician is eligible for this program only if all 8 of the following pertain:
For individual physician applicants, please complete on behalf of yourself.
6. Current Position
Practicing/Attending physician
If physician is presently completing a residency, fellowship,
or other medical training program, indicate the anticipated date of completion. ______ / ______
7. Physicians start date of current employment: _____/_____/_____
8. Expected Start date of position for which applicant is requesting DANY funding: _____/_____/_____
Note: To be eligible for funding the physician must start the position and begin the State service obligation no later than 4/1/16.
9. Specialty:
10. Is identified physician currently licensed to practice as a physician in New York State?
Yes, license number
11. If the identified physician has applied for or received any scholarships, loan forgiveness or other funds for the same or partially overlapping service obligation
period for which he or she is applying in this application, insert the information in the table below.
12. If applying for PPS or PLR funding for loan repayment, provide the physician debt information below (add a separate sheet if necessary):
National Health Service Corps Scholarship
Regents Physician Loan Forgiveness Award Program
National Health Service Corps Loan Repayment Award
Doctors Across New York Physician Loan Repayment
Doctors Across New York Physician Practice Support
Loan Repayment Program – Other (Please specify):
Resident/Fellow
Regents Health Care Scholarship
CREDITOR NAMECREDITOR ADDRESSCURRENT BALANCE
TOTAL $
DATE OF AWARD (if applicable)DATES OF SERVICE OBLIGATIONAMOUNT
Pending, date applied
Currently in residency and has not yet obtained a license
13. TOTAL DANY GRANT FUNDING AMOUNT REQUESTED (May not exceed $150,000 for PLR or $100,00 for PPS) $
If the physician cannot meet all of the above, STOP. The physician is NOT eligible for DANY funding.
The identified physician meets all of the following:
YesNo
• A U.S. citizen or permanent resident alien holding an I-155 or I-551 card;
• Licensed to practice in New York State by the time the service obligation begins;
• Not currently working in, or serving, an underserved area in New York State where the current service to the underserved area began prior to July 1, 2013;
• Not fulfilling an obligation under any state or federal loan repayment program where the obligation periods of the state or federal loan repayment program
would overlap or coincide with the DANY obligation period, including any current DANY obligation;
• Not a past recipient of DANY Physician Practice Support or Physician Loan Repayment funding;
• In good standing with the Department of Health;
1
• Not be in breach of a health professional service obligation to federal, state or local government, or have any judgement liens arising from federal or state
debt; and must not be delinquent in child support payments; and
• Working or plan to work in an eligible employment site listed on page 1 of the instructions.
1
i.e., not excluded from, or terminated by, the federal Medicare or Medicaid programs (see //www.omig.ny.gov/fraud/medicaid-terminations-and-exclusions); not subject to Orders of the State Board for
Professional Medical Conduct (see //w3.health.state.ny.us/opmc/factions.nsf/physiciansearch?openform); or under indictment for, or convicted of, any crime as defined by New York State Penal Code (see
//public.leginfo.state.ny.us/menuf.cgi). Please note that the physician must have updated his or her mandatory Physician Profile (see nydoctorprofile.com/) information prior to the time of application.
DOH-5062 (6/15) Page 3 of 6
Section C. Site Information
Section D. Proposed Specialty
If serving at more than one site, duplicate and complete relevant pages for each site. (see instructions)
Site ____ of ____
1. Name of Site
2. Address
3. Percentage of time spent at this site
4. Location of area served by practice site
5. County(ies) served
6. Town(s) served (if applicable)
7. Neighborhood(s) served (if applicable)
8. Population served (if applicable)
RuralInner CitySuburban
(a) If the physician will be practicing in General Internal Medicine, Family Practice, General Pediatrics, Geriatrics, OB/GYN, and Adult or Child Psychiatry in the
geographic area served by the site(s) listed in this application; AND
(b) the area or site is located in or serves one or more federally-designated Primary Care or Mental Health Professional Shortage Area(s) (HPSA) or Medically
Underserved Area(s) (MUA); OR
(c) is located in a rural town listed in the instructions, then check (a) and (b) or (c) below:
a) General Internal Medicine, Family Practice, General Pediatrics, Geriatrics, OB/GYN, and Adult or Child Psychiatry
c) Rural Area
b) HPSA/MUA and provide the number ______________ and attach the printed page from the website
Then skip Section E of this application.
(d) For all other specialties, AND FOR PRIMARY CARE AND MENTAL HEALTH NOT PROVIDED in an HPSA or MUA or rural area check below.
d) Primary Care/Mental Health Not in HPSA/MUA or Other Specialty
DOH-5062 (6/15) Page 4 of 6
Section E. Identification of an Underserved Area
To be eligible for funding you must check and document any 6 items from the list below and provide supporting documentation for each item checked.
Proposed Service Area (from Section C)
Proposed Site
The service area contains a high percentage of indigent persons demonstrated by (check any of the following):
The service area contains _____% of non-white individuals, which is higher than the statewide average of 34.0%.
The service area contains _____% of employed persons, which is lower than the statewide average of 58.1% for persons
in the civilian labor force (population 16 years and over)
The service area contains _____% children under age 5, which is higher than the statewide average of 6.0%.
The service area contains _____% of adults ages 65 or older, which is higher than the statewide average of 13.6%
For rural health providers: Site is located in a rural town or county as listed in the instructions.
Average waiting time for established patients for routine preventative or follow up appointments with a primary care physician is _____ days,
which exceeds seven (7) days from the initial patient request.
Average waiting time for new patients for routine preventative appointments with a primary care physician is _____ days,
which exceeds fourteen (14) days from the initial patient request.
Average waiting time is greater than 48 hours for patients with urgent appointments or greater than 72 hours for patients with non-urgent “sick visit”
appointments related to the specialty requested.
Search for a practice partner has not produced a physician in 12 months.
Twenty five percent (25%) or more of the sites (or if a hospital, department’s) visits are for indigent care, i.e. Medicaid, Child Health Plus,
free and sliding scale combined as a percentage of total visits.
Proposed Specialty
Currently there are NO other providers offering similar services or there is insufficient capacity of providers for this specialty type
at the proposed service site.
The travel distance from the applicant’s proposed service site to the next closest provider practicing the listed specialty exceeds 20 miles
(Rest of State) or 5 miles (NYC).
Site anticipates a decrease in the number of physicians practicing in the specialty due to announced or anticipated retirements or departures.
Site has employed 1 or more Locum Tenens to provide full time services in the proposed specialty for a minimum of 6 months in the past year.
For specialty care, county(ies) of proposed service area listed above is/are listed in Specialty Shortage Areas (see instructions).
For the hospital serving the site, (or the hospital itself if the applying site is a hospital) the rates of hospitalization for preventable conditions,
or prevention quality indicators (PQI), exceed the statewide rate by 25% for the composite of conditions related to the specialty.
For primary care services only, greater than 25% of all ED visits in the past four months to the hospital served by this site were for non-urgent care.
A percentage of individuals below poverty level that exceeds 14.9% of the population of the service area (for non-NYC areas),
or 19.9% for NYC) and/or
A median family income level lower than $57,683, and/or
A per capita income level lower than $32,104.
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4.
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6.
7.
8.
9.
a.
b.
c.
10.
11.
12.
13.
14.
15.
16.
17.
18.
DOH-5062 (6/15) Page 5 of 6
Section F. Employment Contract or Business Plan
Section G1. Budget Request for Individual Physician Applicants (Physician Practice Support Only)
Be sure to label your documents “Employment Contract” or “Business Plan.”
• All Employment Contracts must be signed by the physician and the employer and reflect a two or five year service obligation period as described in the instructions.
• If the applicant is an individual physician requesting funds to join a practice, please insert a copy of the fully executed employment contract or partnership
agreement.
• If the applicant is an individual physician requesting funds to start a practice, please insert a copy of a business plan as per the instructions.
COST CATEGORYMONTHS 1-24TOTAL FOR
CATEGORY
JUSTIFICATION/EXPLANATION
Qualified Educational
Loan Repayment
Land/Building Acquisition/
Rental
Personnel Salaries
Renovation/Construction
Equipment/Furniture
Investment in Partnership
Other (specify):
TOTAL
DOH-5062 (6/15) Page 6 of 6
Section G2. Budget Request for Facility or Practice Applicants (Physician Practice Support Only)
COST CATEGORYMONTHS 1-24TOTAL FOR
CATEGORY
JUSTIFICATION/EXPLANATION
Income Guarantee
Recruitment Bonus
Productivity Bonus
Relocation Reimbursement
Continuing Medical
Education Costs
Other Cash Payment
to Physician (specify):
TOTAL
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