State Health Agency Requests Q. How do I apply for a waiver based on a request from a State health agency?
A. There are several requirements. Here is a checklist of what you must submit: — Data sheet — Processing fee: check or money order for $136 — A letter from the State health departments designated official (designated by the state governor) which states it is in the “public interest” that the exchange visitor physician remain in the U.S. and includes the following: 1. Exchange visitors name 2. Country of last legal permanent residence 3. Name of medical facility 4. Address of facility 5. U.S. Department of Health and Human Services designated Health Professional Shortage Area (HPSA) ID number of medical shortage area — A letter from the facility that wishes to hire physicians. — Evidence that the facility is in a Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA) — A signed contract for no less than 40 hours a week for three years between the facility and the physician, with signatures of physician and head of the facility. — IAP-66 forms — Curriculu