Supplementary B Clinical Care
Request for Waiver of the Two-Year Foreign Residence Requirement
A Clinical Care application requires that certain supplementary information be provided with the application. Please follow the guidelines below.
- Department of State Data Sheet (2 copies)
- Readable copies of J-1's IAP-66 and/or DS 2019 forms for each year in J-1 status
- IMG Physician Statement [see 22 CRF Chap.1, Sec. 41.63(c)(4)(iii)]. MUST be in exactly this format:
"I, (insert Name of exchange visitor) hereby declare and certify, under penalty of the provisions of 18 U.S.C. 1001, that I do not now have pending nor am I submitting during the pendency of this request, another request to any United States Government department or agency or any State Department of Public Health, or equivalent, other than (insert Name of U.S. Government Agency requesting waiver) to act on my behalf in any matter relating to a waiver of my two-year home-country physical presence requirement." Statement must be signed by the physician and dated.
- Current Curriculum Vitae (CV). Do not include your Social Security number
- Three letters of recommendation from current U.S. residents who know the J-1 physician's qualifications
- Credentials (diplomas, licenses / license application)
- Completed HHS Application Form HHS 426 – Application for Waiver of the Two-Year Foreign Residence Requirement of the Exchange Visitor Program
- Submitter's cover letter and G-28
- A rural health clinic must submit a copy of the Letter of Certification issued by the Centers for Medicare and Medicaid Services
- Letter of need from medical facility, on the facility's letterhead paper. Letter must include the identifier number of the federally-designated underserved area in which the facility is located. &If the physician is to work at more than one site, identifier numbers for all sites must be included.
Also, the letter must include a statement that the facility:
- treats all patients regardless of their ability to pay,
- accepts Medicare, Medicaid, and S-CHIP assignment, and
- uses a sliding fee scale
Letter must be signed by the head of the medical facility, and dated.
- Three letters of community support for the hire of this physician (must include contact information)
- State health department support/acknowledgment letter (if letter has not been received, enclose copy of facility's request for same - letter may be forwarded under separate cover when received)
- Department of State attestation [see 22 CRF Chap.1, Sec.41.63(c)(4)(ii)]
- Copy of executed contract. Contract must:
- be of three years' duration,
- obligate the physician to work 40 hours per week providing out-patient primary care (family practice, general internal medicine, general pediatrics, or obstetrics/gynecology) or general psychiatric services, and
- specify the site in which the physician will work (if more than one, all sites must be located in designated health professional shortage areas (HPSAs) with a score of 7 or higher, and HPSA identifier numbers must be provided)
NOTE: Contract may not contain a non-compete clause or restrictive covenant.
Contract must be signed by the head of the medical facility and the physician, dated, and notarized.
- Prevailing wage form
- Evidence of employer's regional and national recruitment efforts, including names of non-foreign physicians applying and/or interviewed and reasons why they were not hired
- Proof of facility's existence such as a phone book listing (Further documentation may be required.)
For questions regarding Supplementary Information B, Clinical Care, contact:
Bureau of Health Workforce
Health Resources and Services Administration
Department of Health and Human Services
Parklawn Building, Room 11W-56
5600 Fishers Lane
Rockville, MD 20857