Office of Rural Health
J-1 Visa Waiver Application Content
The assigned U.S. Department of State case number MUST appear in the upper right hand corner of each document submitted as part of an application. All documents must be submitted in the following order:
1. Datasheet DS-3035 – A completed U.S. Department of State Data sheet, DS-3035 shall be included in the application.
2. Employment contract – Each application shall include a complete copy of the minimum three-year employment contract between the J-1 physician and the employing facility. The J-1 physician and the employing facility shall sign and date the contract. The employment contract shall include the following:
- Name and address of the employing facility;
- Name and address of the J-1 physician;
- The specific shortage area(s) in which the J-1 physician will practice;
- The J-1 physician will practice full time (an average of 40 hours of medical practice per week, meaning a four week minimum of 128 hours seeing patients on an ambulatory or in-patient basis and 32 hours administrative work for at least 48 weeks per year); in the specified shortage area(s) identified in the contract.
- Subject to approval by the Department, the J-1 physician may opt to practice down to a minimum of 64 hours per four week period direct patient care within the shortage area identified in the contract. In such instances the J-1 physician will provide up to 24 additional hours per week under any of the following conditions:
- providing care to patients in either the hospital inpatient or outpatient department if the hospital is shown to serve a significant portion of shortage area residents;
- Clinical outreach to underserved populations residing in a shortage area, whether directly in person or by electronic means. If by electronic means, the remote site must be located within a shortage area. If provided in person, the setting must be located in a shortage area.
- Public health services if approved by the department; or
- Direct patient care in a facility or setting that serves the underserved, as evidenced by the posting of a notice of a discounted fee program as an adopted policy of the facility. The discounted fee program must follow the following standards: 100% of the federal poverty level (FPL) or less = 100% discount; 101% to 125% of FPL, inclusive, = 80% discount; 126% to 150% of the FPL, inclusive, = 60% discount; 151% to 175% of the FPL, inclusive, = 40% discount; and 176% to 200% of the FPL, inclusive, = 20% discount.
- The J-1 physician will begin employment at such facility within 90 days of receiving the waiver as well as continue to work at the facility for a total of not less than 3 years;
- The J-1 physician must accept assignment under the Social Security Act as full payment for all services for which payment may be made under part B of the Title XVIII of such act (Medicare);
- A sentence describing what field of medicine the J-1 physician will practice;
- Language requiring that the contract be terminated only for cause and cannot be terminated by mutual agreement until after expiration of the required three-year period;
- No non-compete clause or provision that limits the J-1 physician’s ability to remain in the area upon completion of the contract; and.
- A copy of the J-1 Employment Contract Policy of the SD Department of Health (use ADOBE) must be attached to each employment contract.
3. J-1 waiver affidavit – The application shall include an affidavit signed by the J-1 physician. The department shall furnish each J-1 physician a copy of an unsigned affidavit upon request by the employing facility.
4. Federal forms – A copy of the IAP-66/DS-2019 (certificate of Eligibility for Exchange Visitor J-1 Status) for each year the J-1 physician was in J-1 status.
5. Letter from facility - The letter shall request the department to act as an interested governmental agency in recommending waiver of the home country residency requirement for the named J-1 physician. The letter should describe the employing facility, including organizational structure, services offered and service area. The administrator of the employing facility must sign the letter.
6. Evidence of shortage designation status - Each application shall include evidence that the service area is designated as a health professional shortage area or a medically underserved area or both.
7. J-1 physician statement - A statement form the physician regarding the reasons for not wishing to fulfill the two-year home country residence requirement to which the physician agreed at the time of acceptance of exchange visitor status shall be included in the application.
8. J-1 physician curriculum vitae – A copy of the J-1 physician’s curriculum vitae shall be included in the application.
9. Out of status explanation, when applicable - An explanation shall be included in the application if the physician spent any period of time in some other visa status, out of status, or outside of the United States.
10. Form G-28, when applicable - A form G-28 shall be included in the application from an attorney or accredited representative. A letterhead from a law office may be used as a substitute for form G-28 if an attorney represents the applicant.
11. I-94 entry and departure cards - A copy of all I-94 forms for the physician family members shall be included in the application.
12. Contractual obligation to home country – Each application shall contain a statement signed by the J-1 physician, as to whether the J-1 physician is contractually obligated to his or her home country. If so obligated, a copy of a letter from the home country stating it has no objection to the J-1 physician remaining in the U.S. must be attached to the statement.
13. Appendix 1. Information required from facility - The application must include a series of statements, all clearly labeled under a separate heading describing the following:
- Recruitment efforts – The employing facility shall summarize and provide copies of advertisements, any agreements with placement services and other evidence documenting the extent to which the employing facility has been unsuccessful in recruiting qualified U.S. physicians. In the absence of such evidence, a narrative that sets forth in convincing detail such unsuccessful recruitment efforts shall be included.
- Summary of J-1 physician’s expected practice arrangement – The summary shall describe the J-1 physician’s proposed responsibilities and how the J-1 physician’s employment will satisfy important unmet needs of the shortage area. The summary must describe how the J-1 physician will satisfy his or her practice obligation in terms of practice location, practice hours, and responsibility for taking call.
- Equivalency of J-1 compensation – The employing facility shall state the J-1 physician’s salary or other forms of financial support is at a level equivalent to that of other physicians in the region, taking into account such variables as training, experience, and specialty involved. The statement should itemize the guaranteed three-year base salary, benefits, insurance, and amount of leave.
- Retention of J-1 physician beyond the 3-year obligation – The employing facility shall state its plans for retaining the J-1 physician beyond the three-year obligation period.
- Effect of waiver denial – The employing facility shall state the effect on the shortage area population to be served if the waiver is denied.
- Service to the underserved – The employing facility shall describe the shortage area to be served by the J-1 physician and state that the facility accepts Medicare/Medicaid patients as well as medically indigent patients.
14. Appendix 2 - Examinations required by USCIS - Proof of passage of each examination required by USCIS shall be included in the application.
15. Appendix 3 - Eligibility to be licensed to practice – A copy of the J-1 physician’s South Dakota medical license or proof of ability to be licensed in the state of South Dakota by the beginning of the employment contract period shall be included in the application.
16. Appendix 4 - Letters of recommendation - At least three letters of recommendation shall be included in the application.
17. Appendix 5 - Permanent residence – Each application shall include a statement from the employing facility that it will not facilitate the process of acquiring permanent residence for the J-1 physician until after the J-1 physician has been employed in accordance with waiver program requirements for at least two years.
18. Appendix 6 - Medical Licensure – The application shall include a statement signed by the J-1 physician stating that all the J-1 physician’s medical licenses are in good standing and that he or she is not subject to any criminal investigation or proceedings by any medical licensing authority.