T.L.L. Temple Foundation Loan Repayment Program Application

T.L.L. Temple Foundation Student Loan Repayment Program

Participant Application

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE SUBMITTING THE APPLICATION

The purpose of the T.L.L. Temple Foundation (“TTLTF”) Loan Repayment Program is to recruit and retain qualified health providers (including physicians, dentists, nurse practitioners and physician assistants) at eligible sites located in the FoundationTTLTF’s service area. If you are selected for enrollment into the program, loan repayment funds will be reserved for annual disbursement at the end of each 1-year term of service obligation for no more than four (4) years in total for physicians and dentists and no more than two (2) years in total for nurse practitioners and physician assistants. Repayment is contingent upon continued annual funding. We will email the appropriate documents at the end of each year of service for your employer’s verification of your service and for your lender’s verification of loan information.

Eligibile Providers & Requirements

Eligible Providers

Family Practice/Family Medicine Physicians
Internal Medicine Physicians
Pediatrics Physicians
OB/GYN Physicians
Dentists
Nurse Practitioners
Physician Assistant

Requirements:

1. All providers must be a U.S. citizen or permanent legal resident (or otherwise be legally authorized to work in the United States), practicing an eligible type of health care/dental care, and agree to practice at an eligible practice site.

2. Physicians must have a current, unrestricted license from the Texas Medical Board and be board certified or eligible to take the exam from an American Specialty Board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists.

3. Dentists must have a current, unrestricted license from the Texas State Board of Dental Examiners.

4. Nurse Practitioners must have a current, unrestricted license from the Texas Board of Nursing.

5. Physician Assistants have a current, unrestricted license from the Texas Medical Board.

Practice Site Requirements

All clinical sites must be either tax-exempt under section 501(c) (3) of the Internal Revenue Code, a local mental health authority, or a governmental/public health facility (e.g. outpatient clinic, state psychiatric hospital). Sites must be located in one of the following counties:

Anderson, Angelina, Bowie, Cass, Cherokee, Hardin, Houston, Jasper, Jefferson, Liberty, Nacogdoches, Newton, Orange, Panola, Polk, Rusk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, and Tyler.

The site must have a primary focus on serving the underserved, including Medicaid, CHIP, Medicare, and other low-income, under-insured, or uninsured populations. All sites that are eligible to participate in National Health Service Corps (NHSC) programs must have submitted an NHSC site application and be approved for participation in that program. Eligible sites include (i) TTLTF grant partner sites that are Federally Qualified Health Centers (FQHCs); (ii) TTLTF grant partner sites that are non-FQHCs but are nonprofit primary care and/or behavioral health sites, such as Rural Health Clinics; and (iii) FQHCs or nonprofit primary care and/or behavioral health sites that are not TTLTF grant partner sites.

Service Period Requirement

A physician or dentist must serve for at least twelve (12) consecutive months at an approved practice site to qualify for an annual loan repayment award. Regardless of an employee’s status as part-time or full-time, a physician or dentist may receive an annual award for each consecutive 12-month period of service for up to four (4) years in total. While physicians and dentists are encouraged to stay in the program for the maximum duration of four (4) years, they may withdraw from the program at any time; provided, however, that failure to meet the requirement of twelve (12) consecutive months will result in ineligibility to receive an annual repayment award. Four (4) years is the maximum number of service obligations for which a physician or dentist may qualify for repayment.

A nurse practitioner or physician assistant must serve for at least twelve (12) consecutive months at an approved practice site to qualify for an annual loan repayment award. Regardless of an employee’s status as part-time or full-time, a nurse practitioner or physician assistant may receive an annual award for each consecutive 12-month period of service for up to two (2) years in total. While nurse practitioner or physician assistant are encouraged to stay in the program for the maximum duration of two (2) years, they may withdraw from the program at any time; provided, however, that failure to meet the requirement of twelve (12) consecutive months will result in ineligibility to receive an annual repayment award. Two (2) years is the maximum number of service obligations for which a nurse practitioner or physician assistant may qualify for repayment.

Annual Award Amounts & Loan Requirements

If thea participant’s student loan balance is less than the aggregate of the applicable maximum annual award amount (as shown below) times 4($120,000 for physicians/dentists and $30,000 for nurse practitioners/physician assistants), then the annual student loan repayment amounts will be prorated to retire the balance over a period of four (4) years for physicians/dentists and two (2) years for nurse practitioners/physician assistants (contingent upon continued annual grant funding). Awards will also be prorated to the extent the provider is only providing a part-time service. Otherwise, the maximum annual award amount is $30,000/year or $120,000/total aggregate award for physicians/dentists and $15,000/year or $30,000/total aggregate award for nurse practitioners/physician assistants. Additionally:

Once the repayment amounts have been calculated and established, those are the amounts to be paid and will not change (except for change in employment status occurs - full-time to part-time); and
Outside of the loan repayment amounts, any additional loan balance and/or accrued interest is the sole responsibility of the recipient.

To be eligible for repayment, an education loan must:

Be evidenced by a promissory note to pay for the cost of attendance for the provider’s undergraduate or graduate education at an accredited institution in the United States. Loans made during residency are not eligible. If the loan has been consolidated with other loans, the applicant must provide documentation of the portion of the consolidated debt that was originated to pay for the cost of attendance for the provider.
Not have an existing service obligation and must not currently be subject to student loan repayment through another student loan repayment or loan forgiveness program. This includes National Health Service Corps (NHSC). and the Public Service Loan Forgiveness Program (PSLF).

Application Scoring

Received applications will be scored, ranked, and funded based up on the following criteria:

County Level HPSA Score

The County HPSA score of the county in which the provider practices will be used. The HPSA score used will be associated with the Provider type:

Family Practice/Family Medicine/Internal Medicine – Primary Care HPSA
Pediatrics/NP/PA - Primary Care HPSA
OB/GYN - Primary Care HPSA
Dentist - Dental Care HPSA

Provider Type

5pts: Family Practice/Family Medicine and Internal Medicine
4pts: Pediatrics
3pts: OB/GYN
2pt: Dentists
1pt: Nurse Practitioners/Physician Assistants

Practice Site

5pts: FQHCs that are TLLTF-funded grant partner sites.
3pts: TLLTF-funded grant partner sites that are not FQHCs but are
some other nonprofit primary care and/or behavioral health sites.
1pt: FQHCs and other nonprofit primary care and/or behavioral health sites that are not TLLTF-funded grant partners.

Tiebreaker

The applicant located within a county with a higher poverty rate will take priority

Notices and Information

The following notices are provided in accordance with Texas Government Code, Section 559.003(a):

1) With few exceptions, you are entitled on request to be informed what information the Texas Department of Agriculture (TDA) collects about you, and to receive and review the information.

2) Under Section 559.004 of the Government Code, you are entitled to have TDA correct information about you that is incorrect. You may do so by writing to: Texas Department of Agriculture / State Office of Rural Health, TTLTF Loan Repayment Program, PO Box 12847 Austin, Texas 78711

3) The information that TDA collects will be retained and maintained as required by Texas record retention laws (Texas Government Code, Section 441.180 et seq.) and rules. Retention times can vary depending on the information.

Section A: Applicant Information

Name

PrefixFirst NameLast Name

Date

Phone Number

Area CodePhone Number

Email

example@example.com

What type of provider are you?

NPI# (type NA if NA)

Texas License Number:

Are you one of the following?

Are you participating in another student loan repayment program?

Section B: Employer Information

Please enter your work physical address in the website linked below to get your HPSA ID and Name. If you do not have one, then enter N/A. If you work for an FQHC, you will have one for the center. Do not put N/A without checking the link first.

Find my HPSA status

HPSA Name:

HPSA ID:

Are you Hispanic/Latino

Race

Gender

Age

Race , Gender, Ethnicity, Age and Income levels are for demographic reporting purposes only.

Total amount of outstanding debt:

Is this debt from Undergraduate or Graduate level?

Student Loan Servicer

Student loan account number

Loan Statement

Browse Files

Second account number if applicable

Second student loan servier if applicable

Second student loan statement if applicable

Browse Files

Name of Employer Facility

Facility Type

Does your facility have a primary focus on serving the under-served, including Medicaid,CHIP, Medicare, and other low-income, under-insured, or uninsured populations?

Type of Employer

Other

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participants' start date at facility:

Date

Human Resources Representative:

First NameLast Name

Human Resource Phone Number:

Area CodePhone Number

Human Resources Contact Email:

example@example.com

Full-time clinical practice is defined as a minimum of 32.5 hours/ week. Awards for part-time service (minimun 20hours/week) will be proro-rated accordingly. DO NOT INCLUDE ON-CALL TIME:

Average number of hours you serve at this facility:

Average number of hours you engagesin direct patient care at this facility:

Do you work at multiple sites?

What counties do you serve patients in?

Please provide the percentage of time that the participant provides care to patients in each county:

Please describe any other foreign language skills, cultural understandings, or qualities that enhance the participant’s ability to serve the patients at your clinic in a manner that is highly valuable:

Any questions or notes you wish to submit may be typed here. ➡

Section C: Certification

By clicking the submit button below, I represent, warrant, and certify the following:

1. I am a U.S. citizen or a Legal Permanent Resident (or am otherwise legally authorized to work in the United States) and hold a full license, with no restrictions, to practice my profession in the State of Texas.

2. I understand and meet all program eligibility requirements, including the requirement that I am not currently fulfilling another obligation to provide medical services as part of a scholarship agreement, a student loan agreement, another student loan repayment agreement, or an employment agreement.

3. I agree to provide four years of continuous service as a provider at the eligible clinical site described in Part C of this application, with the understanding that I will be released from this agreement if grant funding is not continued beyond current year funding.

4. By my signature below, I authorize my employer to release information regarding my employment to TDA and I authorize TDA to share my application information (including any student loan records submitted by either myself or my lender relating to this program) with the T.L.L. Temple Foundation, with the understanding that TDA and/or the T.L.L. Temple Foundation (and any of their respective agents) may contact me in the future regarding my participation in this program and may use this information for purposes of reporting, auditing, and evaluating the impact of this program.

5. The information contained in all parts of this application is true and correct to the best of my knowledge.

6. I understand that (A) upon acceptance of the application, all information submitted with the application becomes subject to disclosure under the Texas Public Information Act (Texas Government Code Section 552.001 et seq.), unless an exception under the Texas Public Information Act is applicable and (B) the loan repayment awards are disbursed annually following my completion of 12 months of continuous eligible service and are contingent upon continued grant funding.

7. I understand the instructions on this application.

Warning: A person submitting misleading or fraudulent information to the Texas Department of Agriculture in an attempt to obtain financial aid is subject to criminal prosecution.