Florida Department of Health



FLORIDA PHYSICIAN VISA WAIVER TRANSFER REQUEST FORMOnly typed applications will be accepted.I. Physician Information:Name: Last: FORMTEXT ????? First: FORMTEXT ?????Middle: FORMTEXT ?????Email Address: FORMTEXT ????? FL Medical License Number*: FORMTEXT ?????Original Application Year: FORMTEXT ?????USDOS Case #: FORMTEXT ?????Practice Type (select only one): FORMCHECKBOX Family Medicine FORMCHECKBOX Internal Medicine - General FORMCHECKBOX Pediatrics FORMCHECKBOX Obstetrics/Gynecology FORMCHECKBOX Psychiatry FORMCHECKBOX Primary Care Hospitalist FORMCHECKBOX Specialist (specify): FORMTEXT ????? Subspecialty (if applicable): FORMTEXT ?????II. Employer Information:Employer Name: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ??Zip: FORMTEXT ????? County: FORMTEXT ?????Email Address: FORMTEXT ?????Employer Type: FORMCHECKBOX For Profit FORMCHECKBOX Non-Profit FORMCHECKBOX Safety Net ProviderIII. Practice Site Information:Primary Practice Site Location of J-1/HHS Exchange PhysicianFacility/Practice Name: FORMTEXT ????? Weekly Direct Patient Care Hours: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ??Zip: FORMTEXT ????? County: FORMTEXT ?????Contact Name: FORMTEXT ????? Contact Phone: FORMTEXT ????? FORMCHECKBOX HPSA [Score: FORMTEXT ??] FORMCHECKBOX MUA/P HPSA or MUA/P ID Number: FORMTEXT ?????Majority of Practice Patients Are: FORMCHECKBOX Outpatient FORMCHECKBOX Inpatient FORMCHECKBOX Other (specify): FORMTEXT ?????Secondary Practice Site Location of J-1/HHS Exchange PhysicianFacility/Practice Name: FORMTEXT ????? Weekly Direct Patient Care Hours: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ??Zip: FORMTEXT ????? County: FORMTEXT ?????Contact Name: FORMTEXT ????? Contact Phone: FORMTEXT ????? FORMCHECKBOX HPSA [Score: FORMTEXT ??] FORMCHECKBOX MUA/P HPSA or MUA/P ID Number: FORMTEXT ?????Majority of Practice Patients Are: FORMCHECKBOX Outpatient FORMCHECKBOX Inpatient FORMCHECKBOX Other (specify): FORMTEXT ?????Tertiary Practice Site Location of J-1/HHS Exchange PhysicianFacility/Practice Name: FORMTEXT ????? Weekly Direct Patient Care Hours: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ??Zip: FORMTEXT ????? County: FORMTEXT ?????Contact Name: FORMTEXT ????? Contact Phone: FORMTEXT ????? FORMCHECKBOX HPSA [Score: FORMTEXT ??] FORMCHECKBOX MUA/P HPSA or MUA/P ID Number: FORMTEXT ?????Majority of Practice Patients Are: FORMCHECKBOX Outpatient FORMCHECKBOX Inpatient FORMCHECKBOX Other (specify): FORMTEXT ?????Additional Site Locations may be submitted on separate sheet. All location information must be included.III. Patient Information:Provide the total number of active patients with the employer in the previous calendar year, for the specified types of care. If the primary site location is a subset of the employer’s practice, please provide the number of active patients at the primary site.Primary CareSpecialty CareMental Health CareEmployer FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Primary Site Location FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provide a breakdown of each payer type by patient group for the employer for the previous calendar year.Sliding Fee/Charity CareMedicaid (including dual eligibles)Medicare OnlyPrivate Insurance/OtherTotalPediatric (<18) FORMTEXT ???% FORMTEXT ???% FORMTEXT ???% FORMTEXT ???% FORMTEXT ???%Adult (>18) FORMTEXT ???% FORMTEXT ???% FORMTEXT ???% FORMTEXT ???% FORMTEXT ???%IV. Assurances:I hereby acknowledge that all information and statements contained herein are true and do not misrepresent fact. I further acknowledge that I have not evaded or suppressed any information contained in this application or in any of the supporting materials.J-1 Physician SignatureDate FORMTEXT ?????J-1 Physician Printed NameEmployer SignatureDate FORMTEXT ????? FORMTEXT ?????Employer Printed NameTitleAttorney Contact Information (if applicable): Name: FORMTEXT ?????Telephone: FORMTEXT ?????E-Mail: FORMTEXT ?????Application materials should be submitted electronically to: FL.PCO@ ................
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