J-1 Visa Waiver Policy Affidavit and Agreement

Physician's Affidavit and Agreement

I _____________________________________, being duly sworn, hereby request the Minnesota Department of Health to review my application for the purpose of recommending waiver of the foreign residency requirement set forth in my J-1 visa, pursuant to the terms and conditions as follows:

I understand and acknowledge that the review of this request is discretionary and that in the event a decision is made not to grant my request, I hold harmless the State of Minnesota, the Department of Health, any and all State of Minnesota employees, agents and assigns from any action or lack of action made in connection with this request.

I further understand and acknowledge that the entire basis for the consideration of my request is the Department of Health's voluntary participation and desire to improve the availability of primary medical care in medically underserved regions of Minnesota.

I understand and agree that in consideration for a waiver, if one is granted, I shall render primary medical services to patients, including the indigent for a minimum of forty (40) hours per week within a U.S. Public Health Services designated Health Professional Shortage Area or Medically Underserved Area. Such service shall commence not later than ninety (90) days after I receive notification of approval by both the U.S. Citizenship and Immigration Services (USCIS) and the U.S. Department of Labor and shall continue for a period of at least three (3) years.

I agree to incorporate all the terms of this Physician's Affidavit and Agreement into any and all employment agreements I enter and to include in each such agreement a liquidated damages clause, of not less than $__________ payable to the employer. This damages clause shall be activated by my termination of employment, initiated by me for any reason, only if my termination occurs before fulfilling the minimum three year service agreement.

I further agree that any employment agreement I enter shall not contain any provision which modifies or amends any of the terms of this Physician's Affidavit and Agreement.

I understand and agree that my primary medical care services rendered shall be in a Medicare and Medicaid certified facility which has an open, non-discriminatory admissions policy and that will accept medically indigent patients.

I have read and fully understand the "Program Guidelines," a copy of which is attached hereto and is specifically incorporated by reference.

I expressly understand that this waiver of my foreign service requirement must ultimately be approved by the USCIS, and I agree to provide written notification of the specific location and nature of my practice to the Office of Rural Health and Primary Care at the time I commence rendering services, and on a semi-annual basis thereafter.

I understand and acknowledge that if I willfully fail to comply with the terms of this Physician's Affidavit and Agreement, the Department of Health will notify USCIS.

Additionally, any and all other measures available to the Department of Health will be taken in the event of non-compliance.

I declare under the penalties of perjury that the foregoing is true and correct.


Subscribed and sworn to before me

this__________day of______________________, 200_______.

Updated Tuesday, 16-Nov-2010 12:28:43 CST