Minnesota J1 Visa Waiver Program
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Minnesota J1 Visa Waiver Program APPLICATION GUIDANCE 2021 Minnesota Department of Health 625 Robert Street North St. Paul, MN 55155-2538 651-201-3838 health.orhpc@state.mn.us www.health.state.mn.us 09/17/2021 To obtain this information in a different format, call: 651-201-3838
M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Contents
Minnesota J1 Visa Waiver Program .......................................................................................... 1
Application Guidance Part 1: Overview................................................................................. 3
1.1 General Information ............................................................................................... 3
1.2 Program Description............................................................................................... 3
1.3 Application Slots and Timeline ................................................................................ 3
1.4 Eligible Applicants .................................................................................................. 4
1.5 Questions and Answers .......................................................................................... 5
Application Guidance Part 2: Program Details ....................................................................... 6
2.1 Priorities ................................................................................................................ 6
2.2 Federal Shortage Designation Areas........................................................................ 6
2.3 Obtaining a J1 Visa Waiver Application Case Number .............................................. 7
2.4 Flex Waiver ............................................................................................................ 7
2.5 Terms and Definitions ............................................................................................ 8
2.6 Review and Selection Process ................................................................................. 8
Part 3: Application and Submission Instructions...................................................................10
3.1 Application Deadline .............................................................................................10
3.2 Application Submission Details ..............................................................................10
3.3 Application Instructions.........................................................................................11
Part 4: Application Checklist ................................................................................................16
2M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Application Guidance Part 1: Overview
1.1 General Information
• Announcement Title: Minnesota J1 Visa Waiver Program
• Minnesota Department of Health (MDH) Program Website: Minnesota J–1 Visa and
Waiver - Minnesota Dept. of Health (state.mn.us)
• Application Deadline: November 30, 2021
1.2 Program Description
The Minnesota Department of Health (MDH) is committed to improving access to health care in
underserved areas of the state. The Minnesota J-1 Visa Waiver Program, administered by the
Office of Rural Health and Primary Care (ORHPC), is a way to address the shortage of physicians
in rural and underserved urban areas. Due to the difficulties some areas experience recruiting
and retaining physicians, many communities turn to International Medical Graduates (IMG) and
J–1 Visa Waivers to fill their physician vacancies.
The program, sometimes called the Conrad 30 Waiver Program, was created by federal
legislation in 1994. The program is intended to help communities recognized as federal
shortage areas hire International Medical Graduates where recruitment of U.S. trained
physicians has been unsuccessful. IMGs can apply to the U.S. Department of State (DOS)
requesting a waiver to an existing J-1 Visa, allowing them to remain in the U.S. to practice
medicine in designated service areas.
Any application to DOS for a J1 Visa waiver must be accompanied by a recommendation
from the local government of the state the IMG will practice, confirming the applicant fills a
community need for services. The Minnesota J1 Visa Waiver Program allows IMG’s and their
sponsored employer to seek a recommendation from MDH. As defined by the J-1 Waiver
guidelines, the employer of the IMG submits their applications materials to MDH for
review. These applications are then reviewed by a team of reviewers and a list of
recommendations is provided to federal offices.
1.3 Application Slots and Timeline
Through the J1 Visa Waiver program, Minnesota can recommend up to 30 physician waivers for
physicians living and working within Minnesota. Generally, ORHPC received more applications
then we can recommend, and recommendations are allocated through a competitive process.
Types of Waivers Recommendations Estimate
J1 Visa Waiver: practice site is located within designated health shortage area 20 -30
Flex: practice site is outside of shortage area but the employer serves a significant
number of patients within designated medically underserved area(s) Cannot exceed 10
Total Waiver Recommendations 30
3M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Timeline
▪ Application Process Opens: The Application process opens September 17, 2021.
▪ Early Review: Applications received by October 15 will receive an initial review for
minimum legal requirements.
• If the application is incomplete, the Department will notify the applicant’s
representative via email. The applicant will have until the last business day in
November to address the issues identified and submit requested information or
materials.
• If the applicant does not respond to the notification within the given deadline or if the
supplemental materials or information fails to address the issues identified by the
Department, the application will be deemed incomplete and not considered for
approval.
• Applications received after October 15 will not be guaranteed an initial review for
minimum legal requirements.
▪ Application Deadline: MDH will not review applications received after November 30, 2021,
unless fewer than 30 applications has not been received ( see Note below.)
▪ Decision Date/Announcements: MDH anticipates that J1-Visa Recommendations will be
complete and announced to applicants the first week of February 2022.
Note: MDH historically receives more applications that we can recommend. The ORHPC will announce
soon after the last day in November whether 30 complete applications have been received. If 30
complete applications have not been received by the deadline, applications will be received on a first–
come, first–served basis, until 30 complete applications have been received.
1.4 Eligible Applicants
The request to MDH for a waiver recommendation must come from the sponsoring U.S. health
care facility registered to do business in Minnesota, on behalf of a J–1 physician. Please note,
the application cannot come directly from a J–1 physician or physician's representative.
For the facility to seek a waiver recommendation from MDH on behalf of the Physician, the
following eligibility requirements must be met:
▪ The Physician must have an active case number assigned by the U.S. Department of State
(DOS) for their Visa Waiver Request.
▪ Have been admitted to the United States under section 101(a)(15)(J) of the INA to receive
graduate medical training; and hold a visa that is current.
▪ Have a full-time employment contract with the provision the physician agrees to work at
the health care facility practice site in which he/she is employed:
• for a total of not less than 3 years and not less than 40 hours per week,
• and will practice primary care or specialty care medicine within a federally designated
shortage area, or primarily serve patients who reside in shortage area.
▪ Obtained a “no objection” statement in writing from their home country.
▪ Agree to begin employment at the health care facility, specified in the waiver application,
within 90 days of receipt of the waiver, not the date their J-1 visa expires.
4M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M 1.5 Questions and Answers All questions regarding the application process must be submitted by email or phone to paia.health@state.mn.us or 651-201-3856. All answers will be posted within five business days at https://www.health.state.mn.us/facilities/ruralhealth/j1/index.html. Please submit questions no later than 4:30 p.m. Central Time, on November 25, 2021. To ensure the proper and fair evaluation of all applications, other communications regarding this application guideline including verbal, telephone, written or internet initiated by or on behalf of any applicant to any employee of the Department, other than questions submitted to as outlined above, are prohibited. Any violation of this prohibition may result in the disqualification of the applicant. 5
M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Application Guidance Part 2: Program Details
2.1 Priorities
The J–1 Visa Program, sometimes referred to as the Conrad 30 program, is a federal program
managed by the State Department (DOS) for international medical graduates who wish to
remain in the United States to study medicine. The visa allows holders to remain in the U.S.
while their studies are completed. At the completion of their studies, IMGs are expected to
return to their home countries for two years before applying for employment authorization in
the United States.
A J–1 Visa Waiver waives the two-year home residency requirement and allows a physician to
stay in the country to practice, if sponsored by an organization located within in an area
designated by U.S. Department of Health and Human Services (HHS) as a Health Professional
Shortage Area (HPSA), Medically Underserved Area (MUA), or Medically Underserved
Population (MUP) or serving patients who reside in a HPSA, MUA, or MUP.
Through the Minnesota J1 Visa Waiver Program, Minnesota reviews applicant materials for
alignment to these needs, and recommends J–1 physicians’ waiver requests to the DOS. The
IMG Physician must have an active DOS case number and have an employment contract for a
practice site located within a federal designation area.
2.2 Federal Shortage Designation Areas
Shortage designation identifies an area, population, or facility experiencing a shortage of health
care services. There are several types of shortage designations. The criteria and guidelines for
designations are determined by U.S. Health Resources and Services Administration (HRSA).To
determine if the facility or service community where the physician will serve is located within a
Shortage Designation area, you can visit the HRSA website and use a searchable database Find
Shortage Areas (hrsa.gov).
A brief explanation of the different designation types is provided:
▪ Health Professional Shortage Area (HPSA): There are several types of HPSA designations:
• Geographic: based on the ratio between the number of full-time equivalent (FTE)
clinical providers and the patient population within a given area.
• Population: This designation indicates that a subpopulation of individuals living in the
area of designation has insufficient access to care. Population groups include those
below 200% of federal poverty level, groups on Medicaid, migrant farm workers, tribal
or homeless populations, among others.
• Facility: This designation indicates that individuals served by a specific health facility
have insufficient access to care. The types of facilities can include federal and state
correctional institutions, public and nonprofit healthcare facilities, Indian Health
Service facilities and state and county mental hospitals.
▪ Medically Underserved Area (MUA): MUAs have a shortage of primary care health
services within geographic areas such as:
6M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
• a whole county;
• a group of neighboring counties;
• a group of urban census tracts; or
• a group of county or civil divisions.
▪ Medically Underserved Population (MUP): MUPs have a shortage of primary care health
services for a specific population subset within a geographic area. These groups may face
economic, cultural, or language barriers to health care. Some examples include:
• People experiencing homelessness
• People who are low-income
• People who are eligible for Medicaid
• Native Americans
• Migrant farm workers
Additional information and guidelines for understanding the shortage designation can be found
at the HRSA Shortage Designation Branch. What is Shortage Designation? | Bureau of Health
Workforce (hrsa.gov)
2.3 Obtaining a J1 Visa Waiver Application Case Number
To be eligible to apply to the Minnesota J1 Visa Waiver Program, the applicant must have an
active J1 Visa Waiver case number with DOS. This application process is not managed by MDH,
and therefore applicants must initiate the process directly with DOS offices. You can find out
more about eligibility and the steps required for this application process by going to: How To
Apply - BridgeUSAParticipants | BridgeUSA (state.gov).
If an employer or physician has questions before beginning the application process, applicants
can contact paia.vang@state.mn.us, 651–201–3856. The ORHPC can provide technical
assistance around terms and program guidelines to help the employer/facility and the
applicant/physician make a self-determination if they meet the requirements to apply for a
waiver.
Note: MDH advises starting the DOS application process well in advance. This process can take
time, and applications to MDH without this number will not be reviewed.
2.4 Flex Waiver
In order to qualify for a J–1 visa waiver, a physician must show that the proposed practice is
located within a designated health care shortage area. Federal law permits up to 10 of the
state’s 30 annual waiver slots to be used for practice locations outside of designated shortage
area, when the employer can demonstrate that it serves a significant number of patients who
live in shortage areas. These waivers are generally referred to as “flex 10” or “flex” waivers.
In addition to all other documentation required for a J–1 visa waiver, an application for a flex
waiver outside of designated shortage areas must contain documentation that the facility
where the physician will practice has sufficient patients who live in designated shortage areas
7M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M to support the physician of the specialty provided by the physician named in the waiver application. 2.5 Terms and Definitions Employer For purposes of these waiver guidelines, an “organization” is an entity listed as the legal “employer” in the employment contract, which is included in a J–1 visa waiver application filed on behalf of an international physician; or an entity that contracts with a multi-specialty physician practice to provide physician staffing. All applications submitted must be filed by the employer organization. If the employer is a health system, please note the individual Department or Health Care Facility within the organization in which the physician physically works is the facility practice site. Each submitted application must be for the employment of only one international physician. If the employer is submitting more than one application, each application must be submitted separately. U.S. Health Care Facility Practice Site The physical facility(ies) where the physician works is the physician practice site(s). This may be different from the employer’s principal business location, and it must represent where the employee is providing direct service to the patient community. Application information on shortage designation areas, sliding fee scale and charity policy, and data on clients served must align to the practice site and program, and not to the organization or health system as a whole if these are different. 2.6 Review and Selection Process Review Process Recommendations will be allocated through a competitive process with review by a committee. Applications will be initially reviewed by MDH staff for eligibility and minimal legal requirements. Applications that meet the minimum requirements will be forwarded to a review committee for selection of up to 30 applications that best meet the needs of the state. The review will be competitive based on a comparison of all qualified applications filed before the application deadline. Only thirty (30) waivers can be granted per state per federal fiscal year (October 1 through September 30). A J–1 visa waiver will not be recommended by the state until the application has been reviewed and selected by the review committee. Up to 30 applications selected will be submitted to the U. S. Department of State for subsequent federal review. MDH will review all committee recommendations and is responsible for recommendation decisions. The recommendation decisions of MDH are final and not subject to appeal. Additionally: 8
M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
▪ MDH’s participation in the J1 Visa Waiver Program is completely discretionary and
voluntary and may be modified or discontinued at any time.
▪ The submission of a complete waiver package to MDH does not ensure that MDH will
recommend a waiver. In all instances the Department reserves the right to recommend or
decline any request for a waiver.
▪ MDH reserves the right to waive minor irregularities or request additional information to
further clarify or validate information submitted in the application, provided the
application, as submitted, substantially complies with the requirements of this application
guidance. There is, however, no guarantee MDH will look for information or clarification
outside of the submitted written application. Therefore, it is important that all applicants
ensure that all sections of their application are complete to avoid the possibility of failing
an evaluation phase or having their score reduced for lack of information.
Selection Criteria and Weight
The review committee will be reviewing each application to confirm they meet program
priorities. It is the responsibility of each applicant to include and explain in their materials the
most relevant factors the review committee should consider in making its selections.
Applications that meet the following criteria will receive priority consideration:
• Primary Care Physicians. This includes Family Medicine, General Surgeon, General
Internal Medicine, OBGYN, Pediatrician, Psychiatrist.
• Primary practice sites located in Rural Minnesota.
• Primary Practice Sites located in Urban MUA and MUPs.
• Primary Practice sites for organizations with a facility or specialty population HPSA.
Examples include FQHCs, Rural Health Clinics, Health Care for the Homeless, etc.
• Demonstrated cultural competency of the physician applicant
• Physician understanding of the service community they will work within, and other
factors that demonstrate likely retention.
9M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M Part 3: Application and Submission Instructions 3.1 Application Deadline All applications must be received by MDH no later than 4:30 p.m. Central Time, on November 30, 2021. All materials, including hardcopy application materials that are mailed, must be received by MDH by the deadline. Late applications will not be accepted. It is the applicant’s sole responsibility to allow sufficient time to address all potential delays caused by any reason whatsoever. MDH will not be responsible for delays caused by mail, delivery, computer or technology problems. 3.2 Application Submission Details The application process includes the submission of required materials both online and as a paper submission. Original hard copies of all required application materials must be submitted to the ORHPC offices. Additionally, an applicant profile must be created online, with corresponding scans of hard copy application documents uploaded to the online form. All documents must contain the case number assigned by the U.S. Department of State. Incomplete applications will be rejected and not evaluated. The online application form and materials will be used for the application review process. Applications recommended for waiver will then have the hard copy submission of materials forwarded for review to the DOS. It is imperative that hard copy materials match exactly to the documents scanned and uploaded to the online system, and that applicants submit all of the J1 Visa Waiver required application elements. Waiver requests that do not comply with these requirements will be returned to the submitting health care facility without further review. By submitting an application, each applicant warrants that the information provided is true, correct, and reliable. The submission of inaccurate or misleading information may be grounds for disqualification, as well as subject the applicant to suspension or debarment proceedings and other remedies available by law. Online Portal ORHPC requires application submissions to be made through an online Application Portal. If your organization has submitted application to ORHPC through the portal, and you already have a user account, please enter your credentials and log-in. If your organization does not have an account and must create one, reference the guidance “Creating and Managing a User Profile.” The applicant is the Employer. Therefore, the organization profile will be created under the name of the Employer, and the application must be initiated by the Employer. To add collaborators, such as a law firm, to the application, follow the instructions provided in the 10
M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
guidance “Creating and Managing a User Profile.” If you have questions after reading the guide,
Please contact Paia Vang at 651-201-3856 or paia.vang@state.mn.us.
Once in the system, click on the link “apply” located on the upper tool bar on the home page.
You will be redirected to a list of open applications in the system; select the appropriate
program.
Hard Copy Instructions
Submit an original copy of the request packet.
▪ All documents must contain the case number assigned by the U.S. Department of
State. Please locate this number in an easily identifiable area. This number must be present
on every page of every document.
▪ Use a table of contents to index all sections of the application.
▪ Easily and clearly identify each section of the application using dividers. Each section
should contain a title page identifying the specific section.
▪ Tab documents to align exactly to the 14 separate application elements indicated on the
Documentation Checklist.
▪ Request packet contents must be single-sided
▪ Request packet contents must be on 8.5” x 11” paper
▪ Do NOT use staples or binders
Mail application packet to:
Paia Vang
Minnesota Department of Health
Office of Rural Health and Primary Care
625 Robert Street North
St. Paul, MN 55155-2538
3.3 Application Instructions
The online portal has multiple sections of the application. Each section must be fully completed
for the application to be considered.
Section 1: Project Name
Section 1 of the application is the Project Name. This section identifies the applicant.
The project naming convention should contain the following:
Applicant’s first, middle, and last name
If the employer is submitting more than one application for consideration, the employer can
choose to prioritize applications using a numbering convention. This should be entered as "rank
of # of applications." (ex. 3 of 20). If the employer has only 1 application, this can be left
blank. The employer’s priority will be considered in the application process, but will not
supersede the program priorities or competitive review process.
11M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Section 2: Applicant
Section 2 of the application is collecting basic information about the J1 applicant. Basic
information about the Physician includes:
• Applicant’s full legal name (first, middle, last);
• Country of citizenship;
• Applicant’s current address (street address, city, state, and zip);
• Applicant’s profession;
• Type of waiver sought;
• DOS Case number;
• Visa status; and
• Applicant’s board certification or eligibility to practice medicine in Minnesota.
Section 3: Employer and Health Care Facility Practice Site
In Section 3, the applicant will identify the legal employer and location of applicant’s practice
site facilities.
▪ The employer information should align to the legal employer of the physician.
▪ The practice site should be the address where the physician will work. If the legal employer
and the facility site are one and the same, the applicant will fill in the same information for
employer and practice site #1.
▪ If the facility locations use a business name in the community other than the legal name,
provide this name under assumed name (DBA).
▪ If there are more than four facilities locations, please identify the top four facility site
locations on the online application form. The online application form require user to enter
in all addresses of practice site locations; HPSA; and MUA/P IDs. The HPSA and MUA/P ID
field are required fields. If there is not an assigned ID number present, identify the field as
“N/A”.
The original hard copy application packet must match to all locations provided in this section.
Please note, there are multiple documents that must match, so be careful to align the site
locations, addresses, and MUA/P, HPSA ID, etc. across all supporting evidence outlined in the
application.
Section 4: Required Attachments
Scan and upload required attachments of all elements for the J1 Visa application for review.
Each element must be uploaded as separate file, corresponding to the section number listed
below.
1. Summary of Situation: A letter from the head of the facility at which the physician will be
employed that:
• Requests that the Minnesota Department of Health act as an interested government
agency and recommend a waiver for the J–1 physician;
12M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
• Summarizes how the health care facility has attempted to locate qualified U.S.
physicians;
• Describes the physician's qualifications, proposed responsibilities and how their
employment will satisfy important unmet health care needs of a medically
underserved community; and
• States unequivocally that the facility is offering the physician at least three years of
employment in a job that will improve access to healthcare for underserved
Minnesotans, a description of the critical need of the facility's service area and how
the facility will assure that the physician will serve that need.
2. Description of the medical facility: Provide a detail description of the health care facilities
and practice site’s capacity, patient demand, and stability to support physician full time to
meet the three-year service obligation. (If a health care system, the description must also
include information about the practice site specifically). Description should address the
type of services provided and how medical facility and practice site will improve access to
care for resident that have a shortage of care available.
3. Charity Care Policy: Provide a copy of the facility’s Charity Care Policy. Application must
demonstrate that the facility has a written indigent care policy for determining discounts or
charity care based on the patient’s ability to pay. The policy should include the percentage
of clientele annually who receive sliding fee discounts or who are using
Medicare/Medicaid. The policy must be posted in a location that is accessible to patients
and potential patients.
4. Valid contract of employment with the health care facility.
• The application must demonstrate a bona fide offer and acceptance of full–time
employment at a health facility. A copy of the complete contract and term of
employment to begin services within 90 days of receiving a waiver.
• The offer must contain a provision, and the physician must agree, to work at the health
care facility in which he/she is employed for a total of not less than 3 years and not
less than 40 hours per week.
• All required contractual provisions must be in the contract or contemporaneous
attachments, not in subsequent letters of understanding, addenda or amendments.
Contract provisions that are contradictory or include research activities or teaching
that is not incidental to direct patient care are not permitted.
• The contract must document that the physician will practice primary or specialty care
medicine full time in the geographic area or areas which are designated by the
Secretary of Health and Human Services as a shortage designation.
• Addresses of all practice sites should be included in the contract.
5. Provide evidence that facility location(s) are in a Health Care Professional Shortage Areas
(HPSAs), and/or Medically Underserved Areas/Populations (MUA/MUPs). This is a federal
requirement. The federal site for verifying shortage designation on the internet can be
found at http://hpsafind.hrsa.gov.
• Regular request: All practice site(s) location must be located in a HPSA/MUA/MUP
designated area. Application should contain clear documentation for all identified site
locations to demonstrate they meet the shortage designation requirement.
13M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
• Flex request: Practice site(s) that are not located in a HPSA/MUA/MUP designated area
will need to provide clear justification on existing needs for physician to provide
services in the facility location. Application should present clear documentation
illustrating demand for patients care services relevant to specialty care provided by the
applicant. Must also demonstrate that patient served resides in designated shortage
areas. And include calculations used to reach the percentage of patient served.
6. Recruitment and retention efforts: Provide a description of the recruitment/retention
efforts made to recruit U.S. physicians. It must clearly demonstrate that a suitable
replacement for the physician cannot be found through recruitment or any other means. In
addition to the description of the recruitment efforts, include copies of all advertisements,
and agreements with placement services. Also provide a statement detailing the plans for
retaining the physician during and beyond the 3–year obligation.
7. Statement of Denial Impact Letter: Provide a one-to-three-page letter from the facility
director explaining issues specific to the application that will help the review committee
select J–1 visa waiver that best meet the needs of the state. The letter should explain the
impact of on the community if the waiver is denied.
8. Licensure Documentation: Provide a copy of Minnesota medical license or active
application. The physician does not need to have a Minnesota license to apply for a waiver.
Application may also include a verification of the active license application to show the
physician will have a license by her/his start date.
9. Resume/ curriculum vitae and Letter of References: Provide a copy of the applicant’s CV or
resume. Provide up to three letters of recommendation.
10. Immigration Documentations:
• DS-2019 or IAP-66 form for each year the applicant has reside in the U.S.
11. USMLE: Must provide the required examinations of the United State Medical Licensing
Examination (USMLE) steps 1, 2 (in 2 parts), and 3, and the Educational Commission for
Foreign Medical Graduates (ECFMG). Each has its own certificate.
12. Waiver Review Application Data Sheet: Provide a copy of the Waiver Review application
data bar code sheet. This is a federal form used for applying for a DOS case number. For
additional information on how to apply for a case number, check out the DOS Waiver
Review Application Data Sheet website.
13. Waiver Policy and Affidavit Form: Provide a copy of the completed J1 Visa Waiver Policy
and Affidavit form. A copy of the form can be found at Waiver Policy Affidavit and
Agreement.
14. No Contractual Obligation: Provide a statement of non–objection from home government
or a notarized physician statement of no contractual obligation with physician's home
country.
15. Affidavit of Representation: Provide a copy of the completed Notice of Entry of Appearance
as Attorney or Accredited Representative Form G-28 document.
Additional supporting documentation: Additional documents required for submission to DOS
but not included on this list should be added to a new section of the application documents at
the end of the packet. Continue the number sequence and include a corresponding tab for this
section in the hard copy submission. There is also space on the online form to add additional
14M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M documents not required by the State. If the applicant believes these are relevant to the review, they are welcome to upload (ex. dependent immigration documentation). Once the application has been completed and submitted online, a copy of the original file will need to be mailed into the Office of Rural Health and Primary Care. This original packet will be forwarded to the DOS if the applicant is recommended. 15
M I N N E S O TA J 1 V I SA W A IV E R P RO G RA M
Part 4: Application Checklist
Application Elements
Obtain a J1-Visa Waiver Case Number How To Apply - BridgeUSAParticipants | BridgeUSA (state.gov)
Creation of an Online Application in the MDH Application Portal for each physician application.
Complete sponsoring health facility and physician information.
Complete and upload to the online application all required attachments listed below (with J1-Visa Case
Number on every document):
Summary of Situation. A letter from the head of the facility at which the physician will be
1.
employed.
2. Description of the medical facility.
3. A copy of the charity care policy and describe how it is made available.
Valid contract of employment with the health care facility of not less than three (3) years and
4.
40 hours per week.
Documentation that the applicant practice is located in a, or serving a significant client base
5.
from, Professional Shortage Areas. http://hpsafind.hrsa.gov
Description of recruitment and retention efforts, including copies of postings, is required by the
6.
U. S. Department of State (DOS)
Letter from the facility director explaining impact of denial on the community if the waiver is
7.
denied.
Copy of applicant physician’s license to practice medicine in MN, or copy of a pending license
8.
application that will be valid by start of employment.
9. Physician curriculum vitae and up to three letters of recommendation.
Physician's immigration documents: DS–2019 forms of the physician for each year the physician
10.
has been in the country.
Certification by the ECFMG, and proof of passage of United State Medical Licensing
11.
Examination (USMLE) steps 1, 2 (in 2 parts), and 3.
12. Completed Waiver Review Application Data Sheet
13. Completed J–1 Visa Waiver Policy Affidavit and Agreement
14. Physician statement of whether contractually obligated to return to home country.
15. Notice if Entry of Appearance as Attorney or Accredited Representative From (G-28)
Submit the original hard copy of the application packet to:
Paia Vang
Minnesota Department of Health
Office of Rural Health and Primary Care
625 Robert Street North
St. Paul, MN 55155-2538
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