In order for the Kansas Department of Health and Environment Bureau of Community Health Systems to review and process your waiver request, a package of information must be compiled and submitted to:

Ellan Spivey , Primary Care Workforce Coordinator
State Primary Care Office
KDHE Bureau of Community Health Systems
1000 SW Jackson, Suite 340
Topeka, KS 66612-1365

√         All information must be submitted at the same time

√         The Case Number assigned by U.S. Department of State must be recorded on every sheet submitted.

√         Waiver forms should be notarized and have original signatures

√         A complete copy of the application packet should be submitted along with the original

√         Please avoid two-sided documents and use only 8 1/2" x 11" paper.

Required information to be completed and supplied by the J-1 physician for the waiver review application packet:

1.    A copy of the letter with the case number from the United States Department of State and a copy of the Department of State Data Sheet (DS 3035).

2.    Readable photocopies of Physician's DS-2019 forms (former IAP-66"Certificate of Eligibility for Exchange Visitor (J-1) Status") for  covering every period during participation in an exchange visitor program in J-1 status.

3.    Readable photocopies of any I-94 Entry and Departure cards (front and back on the same page).

4.    A letter with an explanation for any period spent:

      •    in some other visa status

      •    out of status or

      •    out of the country

5.    A personal statement regarding the exchange visitor´s reasons for not wishing to fulfill the two-year country residence requirement.

6.    Physician´s curriculum vitae including the physician's social security number.

7.    Qualifications (diplomas, licenses).

8.    Copy of the physician´s Kansas medical license, or demonstration that all medical licensure requirements are met for the State of Kansas.

9.    Notarized Department of State Visitor Attestation form.

10.  Notarized KDHE Attestation form.

11.  If foreign government funding was provided for the exchange visitor program, request a "no objection" statement from the country to which the J-1 visa physician is otherwise obligated to return.  However, the "no objection" statement must be sent directly to the Waiver Review Division from the Embassy and must be on Embassy letterhead and stationery.

Required information to be completed and supplied by employing entity/facility for the waiver review application package:

12.  A letter addressed to the Kansas Department of Health and Environment from the head of the entity/facility with whom the physician will be employed requesting that Kansas Department of Health and Environment act in its capacity as "state health agency" and recommend a waiver for the J-1 physician.  The letter must contain the following:

•     Complete Address where physician will practice if the waiver is granted (county, street address, city and zip code,

•     Description of the sponsoring employer facility or clinical site and the service area

•     A list of all primary care physicians (or specialists) practicing in the area.

•     For non-primary care specialties, detailed description of unmet need.

•     A statement detailing the plans for retaining the physician during and beyond the 3-year obligation

•     Applicant/Physician´s Name

•     Applicant/Physician´s Date of Birth

•     Applicant/Physician´s Country of Origin or last residence

•     Applicant/Physician´s Medical Specialty

       The letter must also describe the physician´s:

•     qualifications,

•     proposed responsibilities, and

•     how the J-1´s employment will satisfy important unmet needs.

13.  Copy of dated, executed contract for no less than 40 hours a week for three years between the facility and the J-1 physician, signed by both the head of the facility and the J-1 physician.  Contract must state that the J-1 physician agrees to begin employment at such facility within 90 days of receiving the visa waiver.

14.  Evidence of unsuccessful efforts for at least six months to recruit an American physician for the position (i.e., medical journal advertisements, labor certifications, cover letters, stating that efforts to recruit an American have been unsuccessful, etc.)

15.  Letters of community support.

16.  Letters of recommendation (three) from those who know the J-1 physician´s qualifications.

17.  NotarizedU.S. Department of State Employer Attestation form signed by the head of the facility at which the J-1 physician will be employed stating that the facility:

•     is located in a designated HPSA or recently designated MUA; and

•     provides medical care to Medicaid, HealthWave, and Medicare eligible patients, and indigent uninsured patients