Physician Information (Applicant) Applicant First Name Language Applicant Middle Name Select which language(s) the applicant has native/multi-lingual or professional medical proficiency. If the applicant has such proficiency in languages not listed, then select "Other" and write in any additional languages.
Applicant Last Name Form Type Date of Birth Sex Country of Birth Department of State Case # Visa Waiver Expiration Date Preferred Phone # Email Home Address Practice Type Work Phone # NPI # Employment Start/End date
Employer Information Employer Name: Medicaid Billing Number: Employer Address: Employer Contact Name: Employer Contact Phone: Email of Contact: Practice Site Type: Urban/Rural Status:
Practice Site #1 Practice Name Medicaid Billing # Practice Type Site Address County Census Tract HPSA # MUA or MUP # FLEX # Hours per Week Working at Site Comments Additional Practice Sites to Enter? (up to 3 additional sites)
Practice Site #2 Practice Name Medicaid Billing # Site Address County Census Tract HPSA # MUA or MUP # FLEX # hours spent at site Comments Additional Practice Sites to Enter? (up to 2 additional sites)
Practice Site #3 Practice Name Medicaid Billing # Site Address County Census Tract HPSA # MUA or MUP # FLEX # hours spent at site Comments Additional Practice Sites to Enter? (up to 1 additional site)
Practice Site #4 Practice Name Medicaid Billing # Site Address County Census Tract HPSA # MUA or MUP # FLEX # hours spent at site Comments
Lawyer/Attorney Information Lawyer Name
Lawyer Email Address: Law Firm Name: Law Firm Address: Lawyer Phone Number: Lawyer Fax Number:
Lawyer Notes:
Document Upload Section Request Letter from the Employer:
Maximum 5 pages
HPSA/MUA Evidence Documents:
If not applicable, please upload a document that states "Not Applicable" with a brief justification (1 sentence).
Maximum 10 pages
Signed Employment Contract:
Maximum 5 pages
DS-2019 (formerly known as IAP-66) Forms:
Maximum 20 pages
I-94, Arrival/Departure Record:
Maximum 20 pages
Curriculum Vitae of J-1 Physician:
Maximum 10 pages
J-1 Physician Attestation (also known as Exchange Visitor Attestation/Foreign Medical Graduate Statement):
Maximum 1 page
Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative:
Maximum 20 pages
Data Sheet (DS-3035) and Supplementary Applicant Information Pages:
Maximum 5 pages
Personal Statement from Physician:
Maximum 2 pages
Letter of "No Objection" from Home Government:
If not applicable, please upload a document that states "Not Applicable" with a brief justification (1 sentence).
Maximum 1 page
An explanation of Out of Status :
If not applicable, please upload a document that states "Not Applicable" with a brief justification (1 sentence).
Maximum 1 page
Third Party Barcode Page Waiver Division Barcode Page:
Maximum 10 pages
Community Support Letters:
Minimum 2 letters
Physician/Employer Status Affidavit
Maximum 5 pages
Site Payer Mix Information
Maximum 5 pages
Application Submission By selecting the "Submit" button below, this application will will be submitted to the Massachusetts Department of Public Health (MDPH). Please ensure that all of the above information is complete and accturate before submitting.
Submission Date:
First Name
* must provide value
Last Name
* must provide value
Conrad-30/J1 Visa Waiver Program
National Interest Waiver
HHS
Date of Birth
* must provide value
M-D-Y
Female Male
Language
* must provide value
Other language
* must provide value
Country of Birth
* must provide value
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Channel Islands Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic DR Congo Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Faeroe Islands Finland France French Guiana Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nepal Netherlands Nicaragua Niger Nigeria North Korea North Macedonia Norway Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Qatar Réunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Somalia South Africa South Korea South Sudan Spain Sri Lanka State of Palestine Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas Timor-Leste Togo Trinidad and Tobago Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Venezuela Vietnam Western Sahara Yemen Zambia Zimbabwe Other
Other Country
* must provide value
Dept. of State Case (DOS) #
* must provide value
Visa Waiver Expiration Date
* must provide value
M-D-Y
Physician Preferred Phone #
* must provide value
Physician E-mail Address
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Primary Care Practice Type
* must provide value
Family medicine/general practice Geriatrics Internal Medicine OB/GYN Pediatrics Psychiatry Other Primary Care Practice Non-Primary Care Specialty
Allergy and Immunology Anesthesiology Clinical Genetics Colon and Rectal Surgery Cytopathology Dermatology Emergency Medicine General Surgery Hospitalist Neurologic Surgery Nuclear Medicine Ophthalmology Orthopedic Surgery Otolaryngology Pathology Physical Medicine and Rehabilitation Plastic Surgery Preventive Medicine Radiology Thoracic and Cardiac Surgery Urology Other Specialty
Other Specialty Practice Type
Physician Work Phone #
* must provide value
M-D-Y
M-D-Y
Employer Name
* must provide value
Employer Medicaid Billing #
* must provide value
Employer Address
* must provide value
Employer City
* must provide value
Employer State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Employer Zip Code
* must provide value
Employer Contact First Name
* must provide value
Employer Contact Last Name
* must provide value
Employer Contact Phone
* must provide value
Email of Contact
* must provide value
Employer Practice Site Type
* must provide value
Certified Rural Health Clinic Community Based Mental/Behavioral Health Care Provider Correction or Detention Facility - Federal Correction or Detention Facility - State Critical Access Hospital Affiliated w/a qualified outpatient clinic Federally Qualified Health Center (CHC, Homeless, Public Housing, School-Based, Mobile Unit/Clinic) FQHC Look-Alike Group Private Practice or Other Eligible Provider Hospital Licensed Health Center Licensed Mental Health Clinic Public Sector Health Facility Small Rural Hospital not-for-profit, outpatient primary care practice State or County Mental Health Hospital Other
If other type, please specify/describe
Employer Urban/Rural Status
Urban Rural
Practice Site 1 Name
* must provide value
Site 1 Medicaid Billing #
* must provide value
Primary Care Practice Type S1
* must provide value
Family Practice Geriatrics Hospitalist (please specify) Internal Medicine OBGYN Pediatrics Psychiatry Other Primary Care Specialty Non-Primary Care Specialty
Other Primary Care Practice Type S1
Practice Site 1 Address Street
* must provide value
Practice Site 1 City
* must provide value
Practice Site 1 State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Practice Site 1 Zip Code
* must provide value
Practice Site 1 County
* must provide value
Practice Site 1 Census Tract
* must provide value
Practice Site 1 MUA or MUP # (if applicable)
Practice Site 1 FLEX
* must provide value
No Yes
Practice Site 1: # of hours to be spent at this site
* must provide value
Yes No
Practice Site 2 Name
* must provide value
Site 2 Medicaid Billing #
* must provide value
Practice Site 2 Address Street
* must provide value
Practice Site 2 City
* must provide value
Practice Site 2 State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Practice Site 2 Zip Code
* must provide value
Practice Site 2 County
* must provide value
Practice Site 2 Census Tract
* must provide value
Practice Site 2 MUA or MUP # (if applicable)
Practice Site 2 FLEX
* must provide value
No Yes
Practice Site 2: # of hours to be spent at this site
* must provide value
Yes No
Practice Site 3 Name
* must provide value
Site 3 Medicaid Billing #
* must provide value
Practice Site 3 Address Street
* must provide value
Practice Site 3 City
* must provide value
Practice Site 3 State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Practice Site 3 Zip Code
* must provide value
Practice Site 3 County
* must provide value
Practice Site 3 Census Tract
* must provide value
Practice Site 3 MUA or MUP # (if applicable)
Practice Site 3 FLEX
* must provide value
No Yes
Practice Site 3: # of hours to be spent at this site
* must provide value
Yes No
Practice Site 4 Name
* must provide value
Site 4 Medicaid Billing #
* must provide value
Practice Site 4 Address Street
* must provide value
Practice Site 4 City
* must provide value
Practice Site 4 State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Practice Site 4 Zip Code
* must provide value
Practice Site 4 County
* must provide value
Practice Site 4 Census Tract
* must provide value
Practice Site 4 MUA or MUP # (if applicable)
Practice Site 4 FLEX
* must provide value
No Yes
Practice Site 4: # of hours to be spent at this site
* must provide value
Lawyer Name (first)
* must provide value
Lawyer Name (last)
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
i-94
* must provide value
DS-2019
* must provide value
Signed employment contract:
* must provide value
HPSA/MUA evidence documents (when applicable}:
Request letter from the employer:
* must provide value
J1 Physician Attestation
* must provide value
G-28 Form
* must provide value
DS-3035 Form
* must provide value
Physician Statement
* must provide value
Explanation of Out of Status
Barcode Page Waiver
* must provide value
Community Support Letters
* must provide value
Employer affidavit
* must provide value
Site Payer Mix
* must provide value
submit date
* must provide value
Today M-D-Y
