To apply for a waiver, the applicant must first obtain a waiver review number from the United States Department of State (USDOS).  Current instructions for obtaining a waiver review number may be found at this site.  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.

 

The waiver application shall consist of the following:

 

A completed Data Sheet;

 

A statement on facility letterhead from the chief administrative officer of a Connecticut health care setting located in a HPSA, MUA or MUP 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;

 

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 full-time for no less than three (3) years;

 

Legible copies of all DS-2019 (formerly IAP-66) forms issued to the applicant;

 

Current evidence of the shortage area designation, along with the Census Tract number for the HPSA, MUA or MUP of the setting in which the applicant will practice (Form DPH-1);

 

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.