• Apply to HCAI Funding
  • {% if request.params.id %} {% assign applvn = entities.eapp_applvn[request.params.id] %}{% endif %}{{ applvn.eapp_name }} – Steven M. Thompson Physician Corp Loan Repayment Program

– Steven M. Thompson Physician Corp Loan Repayment Program

General Information

Please list any other names you go by such as maiden names, nicknames, etc.

Do you have a current and valid M.D. or D.O. license from the California Medical Board or the Osteopathic Medical Board of California?*

Are you a prior or current Office of Statewide Health Planning and Development (OSHPD) or Health Care Access and Information (HCAI) Awardee?*

As defined by Scholarship for Disadvantaged Students program, have you been identified as having a disadvantaged background based on environmental and/or economic factors, or did you receive a federal Exception Financial Need Scholarship?

What percent of your time currently is spent working in reproductive health?

Are you willing to continue or begin providing abortion-related care?

Have you had abortion training or certification?*

Are you currently working at or are you willing to commit to serve for three years in at least one of these population areas?*
  • A health professional shortage area, as designated by the HRSA.
  • A medically underserved area or with a medically underserved population, as mapped by the HRSA.
  • A Maternity Care Health Professional Target Area, as designated by HRSA, or a maternity care desert, as designated by the March of Dimes.
  • A rural area.
  • A California county identified to have no abortion services.
  • An area where the majority of patients are covered under the Medi-Cal program.

If awarded with reproductive health funds, awardees will be contacted by HCAI and a partner organization regarding opportunities related to Reproductive Health Service Corps (RHSC). Award information will be used to evaluate the effectiveness of the RHSC, unless awardees choose not to participate by selecting the option below. If awardee choose to participate, thier information including name, email, profession, grant type, and award date will be used to contract awardees regarding these opportunities and assist with RHSC evaluation. Your information will not be shared with anyone else other than the partner organization conducting outreach and program evaluation. That entity will dispose of your information once outreach and evaluation are complete.

Please respond according to your preference.

Yes, I agree to the sharing of this information as it relates to Reproductive Health Service Corps opportunities and evaluation.

No, I do not agree to sharing of this inform

Do one or more of these situations apply to you?*
  • Were or currently are homeless.
  • Were or currently are in the foster care system.
  • Were eligible for the National School Lunch Program (free and reduced-price meals) for two or more years as a child.
  • Parents or legal guardians did not receive a bachelor's degree.
  • Were or currently are eligible for federal Pell Grants.
  • Received support from the California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) as a parent or a child.
  • Reside or grew up in one of the following areas:
  • A rural area, as designated by the Rural Health Grants Eligibility Analyzer. Use this link to check Rural Health Grants Eligibility Analyzer.
  • A health professional shortage area, as designated by the HRSA.
  • Is an individual with a disability, meaning a person with a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990 (42 U.S.C. Sec. 12101 et seq.) as amended.
  • Were or currently are homeless.

Do you owe an existing service obligation?*

Do you currently work or volunteer for a State of California entity?*

Have you ever worked or volunteered for a State of California entity?*

Profile Information

Please go to your profile page to make updates to this information, as necessary.

Race*

Contact Information

Please provide one unique contact. This should be a person not living with you (preferably relatives) that will know how to reach you should we need to contact you.

Professional Information

Are you certified by the American Board of Medical Specialites (ABMS) or American Osteopathic Association (AOA) Bureau of Osteopathic Specialists?*

By which Board, Committee, or Registry are you certified?*

In what specialty is your certification?

How many years of experience do you have working or training in Health Professional Shortage Areas (HPSAs)?*

Which underserved/underrepresented populations do you have experience working with (paid and/or unpaid)? Please select all that apply.

You indicated that you have experience working with an underserved/underrepresented population above. Please indicate how many years of experience you have providing culturally competent care to this group(s).*

What percent of your time is spent serving adults ages 65 or older?

What percent of your time is spent serving children and youth ages 0 to 25?

Educational Information

SectionPlease provide the name and address of the high school you graduated from or the home address if you were homeschooled or received a GED. Click on the "Not Applicable" checkbox if you did not receive a high school diploma or GED within the United States.

High School Name*

Are you the first member of you family to attend college?*

Highest level of degree obtained?*

I attended medical school outside of the United States

Medical School Name *

Date of Graduation*

If your medical school was instructed in a Medi-Cal threshold language rather than English, please list the language of instruction.

Have you completed a three year residency?*

Was your residency in a primary care specialty?

If Yes, please indicate your specialty (check all that apply)*

If No, please explain:*

Have you completed a medical exchange program or postgraduate training in which you provided services to a population that speaks a Medi-Cal threshold language?*

If Yes, use the Add a Program button to enter each separate program or training

Have you completed a fellowship in a culturally appropriate service delivery?*

If Yes, use the Add a Fellowship button to enter each separate program or training

Employment History and Verification

Enter your current health-related work experience only. You must be working in a qualified facility at the time Grant Agreements are executed. Use the Add a Current/Future Employer button to enter each separate employer. Please make sure to save your Employment Verification Form (EVF) with the following prefix: EVF_ before uploading it at the end of the application.
-You must have at least one current/future employer.
-You must have at least a total of 32 Direct Client Care hours per week.

Educational Debt

Instructions:
  • Upload lenders statements for each loan that you have identified in this application.
  • You may only submit proof of debt for those loans obtained during the course of your undergraduate or graduate education which led to your current license/certification as a qualified provider for this program.
  • You will be required to upload the most current lender statement for each loan (within six (3) months, include the current balance, account number, your name, and the lender's name) inthe Required Documents section of the application. The name on the lender statement must match exactly the name of the applicant. All information entered here must match the uploaded lender statements. If information is missing, your application will be deemed ineligible.
  • If your loans have been consolidated, submit proof of consolidation. Your loans cannot be consolidated with another person's loans or with non-educational loans.
  • Online printouts and/or screenshots are acceptable as long as they include all of the required information.
  • Statements, printouts, and/or screenshots must not be in an editable format.

Educational Debt*

Required Documents

Upload documents to support your application as instructed. If you need to re-upload a document, please delete it and upload the replacement.

Application Certification


Application Certification

I certify that all information in this application is true and accurate to the best of my knowledge, and that the information I have provided in the application matches the information on my submitted documentation. I authorize the Department of Health Care Access and Information (HCAI) to verify any information submitted as part of this application. I understand that falsification of information contained in my application will disqualify my application. I understand that if falsification is discovered after I have been awarded or if I breach my grant agreement, I will be required to repay funds awarded, plus interest and administrative fees. I understand that once submitted, my application and supporting documents become property of HCAI.

I understand that, if awarded the Loan Repayment, I am agreeing to the below terms:
  • Return all correspondence in a timely manner
  • Sign a grant agreement. I would be entering into a signed, grant agreement with the California Department of Health Care Access and Information (HCAI)
  • When requested, submit an Employment Verification Form (EVF) for each current employer
  • When requested, submit Progress Reports, signed by my supervisor(s) to verify that I am working and meeting the program requirements
  • Work full time (minimum of forty (40) hours per week) for a minimum of 45 weeks per year
  • Provide direct patient care (minimum of thirty-two (32) hours per week) or twenty-one (21) hours per week if OB/GYN. DPC must be provided on an outpatient-basis ONLY.
  • Maintain employment at a qualified facility for a period of thirty-six (36) months
  • Notify HCAI of any changes to my address, email, phone number, employment, and any leave of absence from work, within 7 days
  • Not accept any other award with other entities, including other HCAI programs, which require me to fulfill a contract that overlaps with this service obligation
  • Subject to repay funds received, with interest, if I do not comply with the terms of the grant agreement