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MONTANA RURAL
PHYSICIAN INCENTIVE
PROGRAM
APPLICATION INSTRUCTIONS
Up to two application cycles may be offered each year depending upon demand for the Montana Rural Physician
Incentive Program (MRPIP). The application deadline(s) is/are typically in January and/or July each year. The
current application cycle is now open with an application deadline of July 1, 2015. The MRPIP
application is a joint application to be submitted by both the physician and the supporting organization or
institution (such as a hospital or clinic) located in the community where the physician is practicing or is
considering practice. The application form contains sections for both the physician and supporting
organization/institution to complete.
A separate loan information and verification form must be completed by both the applicant and lending
institution for each individual educational loan submitted for repayment consideration. Only verifiable medical
education debt qualifies for repayment. All loan consolidations must include a detailed breakdown of each
original loan included in the consolidated loan, clearly identifying the original loan amounts and original
disbursement dates. Medical education debt may include undergraduate education debt, but cannot include
debt incurred during residency training. A physician who qualifies is not guaranteed the maximum repayment
amount.
Program benefits may allow up to a maximum of $100,000 in loan repayment benefits to be applied toward
qualified medical education loans for full-time participating physicians over a one- to five-year period of service
in an approved location. Proportionately reduced repayment amounts are available for physicians practicing
less than full-time. The maximum eligibility period is five years; awards are not made retroactively. Physicians
participating in a federal or Indian Health Service (IHS) loan repayment program or while completing a federal
or IHS practice obligation are not eligible for MRPIP participation until completion of their federal or IHS eligibility
period.
The supporting organization/institution must include additional documentation explaining the need for
assistance with physician recruitment and retention in their community with their section of the application.
This documentation should include at a minimum, a statement addressing the following: 1) the efforts made to
recruit physicians over the past five years, 2) the number of physicians lost to retirement or relocation over the
past five years, and 3) the reasons why recruitment will continue to be a problem for the community. A copy
of the applicant’s current curriculum vitae or résumé must be included with the application materials.
Applications are to be submitted to the following address:
OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION
MONTANA UNIVERSITY SYSTEM
2500 BROADWAY
P O BOX 203201
HELENA, MT 59620-3201
(406) 444-0322 (Phone)
(406) 444-1469 (Fax)
CURRENT APPLICATION CYCLE DEADLINE – JULY 1, 2015
Further information regarding the program and application process may be obtained by contacting Laurie Tobol with the Office of
the Commissioner of Higher Education at (406) 444-0322 or by email at: [email protected].
-1-
APPLICANT CHECKLIST AND INSTRUCTIONS
Application Materials to be completed by physician applicants*:
Pages 1-3 of the MRPIP Application Form
Page 1 (Part A) of the Loan Information and Verification form for each medical education lender to be considered
for loan repayment
1. Submit the completed page 1 along with the incomplete page 2 to the lending institution(s)
2. If loan(s) is/are consolidated, then will also need the individual loan amounts and original loan dates
Copy of a current Résumé or Curriculum Vitae
*Additional documents may be requested if necessary upon initial review of application.
Application Materials to be completed and submitted by Supporting Institution:
Page 4 of the MRPIP Application Form
Letter explaining the need for assistance with physician recruitment and retention in their community including at
a minimum the following information:
1. The efforts made to recruit physicians over the past five years
2. The number of physicians lost to retirement or relocation over the past five years
3. The reasons why recruitment will continue to be a problem for the community
Application Materials to be completed and submitted by Lending Institution(s):
Page 2 (Part B) of the Loan Information and Verification form for each medical education lender to be considered
for loan repayment.
1. The lending institution should return both completed pages back to the applicant to submit with application
Instructions:

DO NOT PRINT YOUR APPLICATION MATERIALS 2-SIDED; SUBMIT SINGLE SIDED MATERIALS
ONLY.



Print legibly in blue or black ink or type your application and loan information and verification forms.
Complete all application materials clearly and completely. Incomplete applications will not be accepted.
Include your last, first, and middle name; full middle name is required. If your legal name does not include a
middle name, please indicate “No Middle Name”, DO NOT LEAVE BLANK.
Current mailing address and telephone number must reflect where you can be reached throughout the entire
application year. If you move or your contact information changes, notify our office immediately via email to:
[email protected]

Completed applications and supporting documentation should be returned no later than July
1, 2015 to the address listed above. If you are sending your application materials via email,
please use the following secure email address to do so: https://securemail.mus.edu
-2MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM
APPLICATION FORM - SECTION 1
(TO BE COMPLETED BY PHYSICIAN)
NAME:
__________________________________ _________________________________ ________________________________ ______________________________
(Last)
(First)
(Middle)
(Maiden)
DATE OF BIRTH:
____________________________________
SOCIAL SECURITY NUMBER: ___________________________________________
PLACE OF BIRTH:
_____________________________________
EMAIL ADDRESS: ________________________________________________________
CHECK APPROPRIATE BOX:
HOME ADDRESS:
HOME PHONE:
US Citizen
US National
Foreign National
of country ______________________________
_____________________________________
MT CLINIC/BUSINESS NAME & ADDRESS: ____________________________
_____________________________________
_____________________________________________________________________________
_____________________________________
BUSINESS PHONE: _______________________________________________________
HIGH SCHOOL GRADUATION: ________________________________________________________________________________________ ______________________
(Name and Location of High School)
(Graduation Date)
SCHOOL OF MEDICINE OR OSTEOPATHY ATTENDED: ___________________________________________________________________________________
(Name and Location of Medical School)
DATES ATTENDED: _____________________________________ DEGREE AWARDED: MD
DO
AWARD DATE: ____________________
WAS YOUR MEDICAL EDUCATION SUPPORTED THROUGH EITHER WWAMI OR WICHE?
Yes
No
If yes, which state supported you: ______________________________________________________
RESIDENCY EXPERIENCE:
Dates:
__________________________________________________________________________________________
Specialty:
__________________________________________________________________________________________
Institution:
__________________________________________________________________________________________
Location:
__________________________________________________________________________________________
RESIDENCY PROGRAM DIRECTOR AND CONTACT INFORMATION:
Name
Address
Phone Number
WORK EXPERIENCE SINCE LEAVING TRAINING: _________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
SPECIALTY BOARD CERTIFICATION:
Yes
No
Date:
__________________________
LICENSED TO PRACTICE MEDICINE:
Yes
No
State(s):
__________________________
HAVE YOU EVER BEEN SUBJECT TO DISCIPLINARY ACTION? Yes
No
If yes, please explain: ________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
HAVE YOU EVER HAD A PROFESSIONAL LICENSE SUSPENDED OR RESTRICTED?
Yes
No
If yes, please explain: ________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
-3MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM
APPLICATION FORM – SECTION 1 CONTINUED
PROFESSIONAL REFERENCES:
Name
Address
Phone Number
OUTSTANDING MEDICAL EDUCATION DEBT:*
Name of Lending
Institution
Mailing Address
Phone Number
Account Number
Account
Balance
* Please complete a separate loan verification form for each loan being submitted for loan repayment consideration.
IS THE APPLICANT SITE A FEDERALLY DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA?
Yes
No
Medical HPSA Score: __________________
HAVE YOU APPLIED FOR FEDERAL OR HPSA FUNDS?
Yes
No
To Be Determined
If yes, list your approval date and eligibility period: _____________________________________________________________________________________
(Please submit a copy of your award letter as verification.)
If no, indicate the date you will file an application, or if no filing is expected, please explain: ________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
NOTE: Federal repayment assistance may be available under the National Health Services Loan Repayment program. All MRPIP
candidates are expected to apply for such benefits if the practice area/location qualifies. State and federal loan repayment benefits
cannot be received concurrently; only qualified medical school loan debts not eligible for repayment under a federal loan repayment
program are eligible for repayment under the MRPIP. Physicians participating in a federal or Indian Health Service (IHS) loan repayment
program or while completing a federal or IHS practice obligation, are not eligible for MRPIP participation until completion or fulfillment
of their federal or IHS eligibility period. Physicians must notify the Commissioner of Higher Education if and when participation in a
LOCATION
________________________________________
TYPE OF PRACTICE: ________________________________
federal or IHSOF
loanPRACTICE:
repayment program
begins and ends.
PRACTICE IS EXPECTED TO BE:
Full-Time
Part-Time
DATE PRACTICE IS EXPECTED TO BEGIN OR DID BEGIN: _______________________________________________________________________________
REASONS FOR CHOOSING THIS SITE FOR PRACTICE: ___________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE:
_________________________________________________________________________
(Signature of Physician)
_________________________________________________________________________
(Date)
-4MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM
APPLICATION FORM - SECTION 2
(TO BE COMPLETED BY SUPPORTING INSTITUTION)
SUPPORTING INSTITUTION: ________________________________________________________________________________________________________________
ADDRESS: ____________________________________________________________________________ ______________________________________ ________________
(Physical Address)
PHONE:
(City)
_________________________________________________________ FAX:
(Zip)
_______________________________________________________________
CONTACT: _________________________________________________________ EMAIL: _______________________________________________________________
(Name and Title)
POPULATION OF SERVICE AREA:
___________________________________
SERVICE AREA
POPULATION/PHYSICIAN RATIO: _______________________
HOSPTIAL SIZE (BEDS): _____________ NAME/LOCATION OF LOCAL HOSPITAL: ______________________________________________________
DOES APPLICANT PHYSICIAN HOLD PRIVILEGES AT LOCAL HOSPITAL?
Yes
No
IF NOT, AT WHAT HOSPITAL DOES APPLICANT HOLD PRIVILEGES? __________________________________________________________________
(Name/Location)
LIST ALL PRIMARY CARE PHYSICIANS PRACTICING IN THE SERVICE AREA (Attach additional sheet if necessary):
Name
Type of Practice
CAN THE COMMUNITY DEMONSTRATE A HISTORY OF EXPERIENCING DIFFICULTY WITH RECRUITMENT AND RETENTION
OF PRIMARY CARE PHYSICIANS?
Yes
No
SUPPORTING INSTITUTION/ORGANIZATION: In addition to this section of the MRPIP application, please submit
documentation explaining the need for assistance with physician recruitment and retention in the community,
including at a minimum, a statement addressing 1) the efforts made to recruit physicians over the past five years, 2)
the number of physicians lost to retirement or relocation over the past five years, and 3) the reasons why
recruitment will continue to be a problem for the community.
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE:
_________________________________________________________________________
(Signature of Institution Official)
_________________________________________________________________________
(Title)
_________________________________________________________________________
(Date)
LOAN INFORMATION AND VERIFICATION FORM
THE MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM
MONTANA UNIVERSITY SYSTEM
OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION
2500 BROADWAY
HELENA, MT 59620-3201
The following information must be provided for each individual loan you are submitting for repayment consideration under the
Montana Rural Physician Incentive Program. Print clearly or type completely to help expedite verification. Please note that incomplete
information may delay verification of your loan(s). Once the lending institution has completed their section of the form, please attach
a current statement of account to the completed forms and submit with your application materials.
APPLICANT: PLEASE COMPLETE ONE COPY OF THIS FORM FOR EACH LOAN YOU ARE SUBMITTING FOR REPAYMENT CONSIDERATION UNDER THE MONTANA
RURAL PHYSICIAN INCENTIVE PROGRAM (MRPIP). PLEASE PRINT CLEARLY AND BE SURE TO COMPLETE ALL OF PART A TO EXPEDITE VERIFICATION.
UPON COMPLETION OF PART A, SEND THIS FORM TO YOUR LENDER TO COMPLETE THE VERIFICATION CONTAINED UNDER PART B AND HAVE THEM
RETURN THE COMPLETED FORM BACK TO YOU. THEN SUBMIT BOTH COMPLETED FORMS (PART A AND PART B) WITH YOUR CURRENT STATEMENT
OF ACCOUNT AND APPLICATION MATERIALS TO THE OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION (OCHE).
LENDING INSTITUTION: PLEASE COMPLETE PART B ON THE NEXT PAGE OF THIS FORM AND RETURN TO THE APPLICANT IDENTIFIED IN PART A.
PART A – TO BE COMPLETED BY APPLICANT
I. APPLICANT AND LENDING INSTITUTION INFORMATION:
________________________________ ________________________________ ______________________________ ___________________________ __________________________
Applicant Last Name
First Name
Middle Name
Birthdate
Social Security Number
______________________________________________________ ________________________________ __________ _____________________ ______________________________
Address (Street and/or PO Box)
City
State
Zip
Telephone Number
______________________________________________________ ______________________________ ______________________________ _________________________________
Lending Institution Name
Telephone Number
Fax Number
Loan Account Number
___________________________________________________________________________ _________________________________________ __________ _____________________
Address of Lending Institution (Street and/or PO Box)
City
State
Zip
II. LOAN INFORMATION:
Purpose of Loan: ________________________________________________________________ Type of Loan: _____________________________________________
(As indicated on loan application)
(Stafford, Health Professions, etc.)
Loan Account Number: _________________________________________________________ Original Date of Loan: ____________________________________
Original Amount of Loan: ______________________________________________________ Current Balance: __________________________________________
Current Balance Date: ____________________________________
Is this a consolidated loan?*
Yes
No
*FOR CONSOLIDATED UNDERGRADUATE AND GRADUATE EDUCATION LOANS: If you have consolidated your loans for undergraduate and graduate
education costs, you must attach documentation outlining the individual loan numbers, loan dates, and loan amounts that were consolidated
into the new loan.
WARNING: Any person, who knowingly makes a false statement or misrepresentation in this loan repayment transaction,
fraudulently obtains repayment for a loan, or commits any other illegal action in connection with this transaction is subject to
repaying any amount received from this program plus 8% interest. I have read this statement and understand its contents.
CERTIFICATION AND ACCOUNT AUTHORIZATION BY APPLICANT:
I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Office of the Commissioner
of Higher Education for repayment towards the medical education loans I have submitted with my application hereof. These loans
were incurred solely for the costs of medical education. I hereby authorize the financial institution named in Section I from
above to release all loan account information to the Montana University System, OCHE for purposes of my participation in
the Montana Rural Physician Incentive Program (MRPIP) from this point forward throughout the duration of my loan
repayment program participation as necessary.
____________________________________________________________________________________________________
__________________________________________
Signature of Applicant
Date
-2LOAN INFORMATION AND VERIFICATION FORM
THE MONTANA RURAL PHYSICIAN INCENTIVE PROGRAM
PART B – TO BE COMPLETED BY LENDING INSTITUTION
The individual identified on the first page of this form has applied to participate in the Montana Rural Physician Incentive Program
(MRPIP) and states that, to the best of his/her knowledge, the loan information provided is a bona fide legally enforceable
commercial, state, government, or private educational loan (no personal loans) made for the purpose of meeting the borrower’s
costs of attending a school of medicine or osteopathic medicine. Please verify this information according to your records by
completing the information below.
Account Holder Name:
_____________________________________________________________________________________________________
Account Number:
_____________________________________________________________________________________________________
Original Amount of Loan:
_____________________________________________________________________________________________________
(For consolidations, please include details regarding the original loans/amounts included in consolidation.)
Original Date of Loan:
_____________________________________________________________________________________________________
(For consolidations, please include details regarding the original loans/dates included in consolidation.)
Current Loan Balance:
_____________________________________________________________________________________________________
Lending Institution/Loan Servicer*:
_____________________________________________________________________________________________________
(Payment Address)
(Name)
_____________________________________________________________________________________________________
(Mailing Address)
______________________________________________________________ ____________ _________________________
(City)
(State)
(Zip)
_________________________________________________ ___________________________________________________
(Telephone)
(FAX)
_____________________________________________________________________________________________________
(Federal Tax ID Number)
*LENDER – SUBMIT COPY OF W-9 WITH VERIFICATION FORM (required for Payment Processing)
Person to contact regarding current loan balance prior to disbursements:
________________________________________________________________
(Name)
________________________________________________________________
(Department)
________________________________________________________________
(Telephone)
Comments:
I hereby certify to the accuracy of the loan information contained on the first page of this form or as provided by the above
notations and comments.
________________________________________________________________
(Signature)
________________________________________________________________
(Title)
________________________________________________________________
(Date)
PLEASE RETURN THIS FORM TO THE APPLICANT IDENTIFIED IN PART A ON THE PREVIOUS PAGE.