Facilities serving patients who reside in one or more designated shortage areas

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 Application".
The waiver application shall consist of the following:
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 must attest that 30% of the health care facility'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; 
The health care facility must 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.