MDCH - MSLRP Application Forms and Process

MSLRP Application Forms and Process

The Michigan Department of Community Health invites all eligible primary care medical, dental, and mental healthcare providers working at HPSA-eligible practice sites to apply for the Michigan State Loan Repayment Program. Providers' practice sites must be located in a Health Professional Shortage Areas or have HPSA facility designations. However, unlike the National Health Service Corps (NHSC) Loan Repayment Program, HPSA scores are not considered in the MSLRP selection process.

Application Forms:

Documents 1 through 3 must be included as part of your Complete, Single-submission MSLRP Application Package.

1. Provider Application, Part A

2. Provider Application, Part B

3. Practice Site Application & Declaration of Intent

Providers complete the Provider Application, Parts A and B, and employers complete the Practice Site Application & Declaration of Intent.

Employers may request ‘Top Priority Status' for their obstetric service providers by checking ‘Obstetric Service Provider' under the ‘Priority Provider Status Request' section on their Practice Site Applications and submitting the Obstetric Provider Priority Request form below.

4. OB Service Provider Priority Request Form

Application Process:

All documents must arrive together at the MSLRP Office by mail in a single envelope and each document must be 100 percent complete and legible. If any portion of an application is incomplete or illegible, it will not be reviewed. Furthermore, due to the volume of applications received, the MSLRP Office will not be able to contact providers and employers regarding incomplete or illegible portions of their applications.

Although complete instructions are included on each application from, a few points may be helpful in submitting a successful MSLRP Application package.

Employment Requirement:

Providers must have an agreement of employment at a HPSA-eligible practice site before applying for MSLRP. Once an agreement is reached, providers may submit their application packages even though they may not start employment until several months after the end of the current fixed application period. Since employers are required to make employer contributions, employers and providers must agree upon the amount of loan repayment before applying and include those amounts in their respective application forms.

Provider Application, Part B:

This form takes the longest to complete, so providers should get an early start by completing the top section and sending a form to each organization that holds one or more of their loans. Starting early increases the likelihood providers will receive their Parts B back in time to complete their application packages and mail them with postmarks no later than the last day of a Fixed Application Period. Providers can save considerable time by faxing or emailing the forms to the holders of their loans and asking them to fax or email them back. Providers should not instruct the holders of their loans to send completed Part B forms to the MSLRP Office. The MSLRP Office will not see these forms, and they will likely be discarded, requiring the provider to start over.

Practice Site Application:

Employers often forget to complete sections of their Practice Site Applications and do not include required attachments, making the application packages incomplete. Employers should pay close attention to completing the sections requiring them to list all Qualified Health Plans (QHPs) with which each of their providers' practice sites participate, and to include their Proof of Tax Exempt Status and their Discounted/Sliding Fee Schedule and Discount Fee Policy. Complete instructions are included on the Practice Site Application & Declaration of Intent form.

Providers must mail completed MSLRP application packages to:

Ken Miller, MSA

Specialist

MSLRP Office

Health Planning and Access to Care

Michigan Department of Community Health

Capitol View building, 7^th Floor

201 Townsend

Lansing, MI 48913-0001

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