La. Admin. Code tit. 48 § V-13311

Current through Register Vol. 50, No. 9, September 20, 2024

Section V-13311 - Application

A. Program guidance and required forms will be updated as necessary on an annual basis and posted on the LDH website. Applications and other required documents shall be submitted directly to the Louisiana Department of Health at the address or using the electronic upload method noted in the program guidance. All applications (hard copy or an online application) must include the following:

1. copy of executed employment contract for the length of years participating in this program or a letter verifying employment, if an employment contract is not available;

2. resume;

3. copy of current professional license;

4. documentation of the current principal balance of the applicant's certified educational debt, including name and account number for each loan;

5. signed release from liability form;

6. signed consent for release of information waiver of confidentiality form;

7. completed IRS Form W-9 Request for Taxpayer ID Number that matches applicant address;

8. completed Electronic Funds Transfer Form with voided blank check or direct deposit form from a financial institution. The bottom of this form should be completed by your financial institution. Please make sure the box on the middle left page is checked;

9. for public employee(s), a letter of agreement with the governmental agency and verification of employment will be accepted in lieu of an employment contract.

La. Admin. Code tit. 48, § V-13311

Promulgated by the Department of Health, Office of Public Health, LR 49, Amended LR 491744 (10/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:1205.1 et seq.