To apply for a waiver, the applicant must first obtain a waiver review number from the United States Department of State (USDOS).  Please follow the instructions for a “Request by a Designated State Department of Health, or its equivalent”.  Please insure that your waiver review number is on each page submitted in support of your application and provide an indication on the cover page of the application that it should be considered as a "Flex 5 Application".
 
In no event shall the number of applications approved exceed the federally designated maximum for Conrad Flex spots per fiscal year.  In no event shall more than two waivers be recommended per health care setting in each fiscal year, unless by April 30 of that fiscal year the number of applications approved and recommended from all institutions does not reach the maximum for Conrad Flex spots for that fiscal year.
 
To apply for a waiver, the applicant must first obtain a waiver review number from the United States Department of State (USDOS).  Please follow the instructions for a “Request by a Designated State Department of Health, or its Equivalent”. 
 
The waiver application shall consist of the following and be sent directly to this office:
 
A completed Data Sheet which may be downloaded at USDOS;
 
A statement on facility letterhead from the chief administrative officer of a Connecticut health care setting indicating the name of the facility, the name of the physician on whose behalf the application in being submitted, the name of the facility contact person and such person’s telephone/fax numbers and email address;
 
Legible copies of all DS-2019 (formerly IAP-66) forms issued to the applicant;
 
Evidence that efforts to recruit an American physician have failed (i.e. copies of advertisements for vacant positions);
 
A current curriculum vitae, including Connecticut license number, date issued, specialty area of practice and exact dates of all post graduate medical training completed;
 
A signed copy of the employment contract between the Connecticut licensed physician and the employing setting indicating the name and address of both parties and the specific geographic area or areas designated by the USDHHS as having a shortage of health care professionals in which the licensed physician will practice medicine.  The employment contract shall include a statement by the foreign medical graduate that he or she agrees to meet the requirements set forth in section 214(l) of the Immigration and Nationality Act and that the physician agrees to begin employment within 90 days of issuance of the waiver.  The contract shall stipulate that the physician will practice medicine for no less than 3 years for at least 40 hours per week;
 
The health care facility shall also:
Document that a minimum of 30% of the applicant physician’s patients reside in an area designated by the United States Secretary of Health and Human Services as having a shortage of health care professionals;
 
Provide a description of why the physician’s services are required and how the applicant physician’s work will benefit the indigent and medically underserved;
 
Provide letters of community support from at least three (3) community agencies stating that the J-1 placement is critical and will help alleviate health care access problems for the underserved population of the community.
The application should be submitted directly to:
 
Connecticut Department of Public Health
J-1 Visa Waivers
410 Capitol Ave., MS#12 APP
P.O. Box 340308
Hartford, CT 06134
 
Questions regarding the application process may be submitted to the Practitioner Licensing and Investigations Section via email.