Thank you for your interest in the RI Health Professional Loan Repayment Program!
This online form is the Application for the 2025 cycle of the loan repayment program. To complete your application, you will need to submit the supporting documents listed below to the Office of Primary Care and Rural Health by February 28, 2025. For your convenience, a checklist and supporting document forms can be downloaded here.
NOTE: Your application will be incomplete if supporting documents are not submitted by the application deadline. The deadline to complete the online application and submit your supporting documents is February 28, 2025. Supporting documents need to be delivered or postmarked by February 28, 2025. For more information, check out our FAQs regarding the program and application process on: https://health.ri.gov/programs/detail.php?pgm_id=179
Required Supporting Documents:
I. Required supporting documents from the health professional:
- Copy of the health professional's current resume or curriculum vitae (maximum of 5 pages)
- Copy of the health professional's current Rhode Island professional license
- Proof of US citizenship (provide a copy of passport or birth certificate)
- Health professional's qualifying loan statement(s)
- Please provide the most recent student loan balance staement and account information from your lenders
- W-9 (Verification of Taxation Reporting Information) Download at https://www.irs.gov/pub/irs-pdf/fw9.pdf
- Paystub from your practice site(s)
- Please submit a copy of your paystub from the month prior to, or the month of, the application deadline
- Credit Authorization and Privacy Disclosure Form
- If applicable:
- Documentation of certification by the International Certification and Reciprocity Consortium (C and RC) or the Association for Addiction Professionals (NAADAC) to provide substance abuse services
II. Required forms and supporting documents from employer/ practice site:
- If your employer is listed in the HPLRP Approved Site, your site administrator will need to complete the following:
- Payor Mix Information Form
- Employer Eligibility Attestation
- Letter of confirmation of employement
For convenience, the forms listed above and instructions are included in the checklist and supporting documents packet provided as part of this application.
FOR EMPLOYER FORMS, PLEASE SUBMIT ORIGINALS WITH SIGNATURES
- If your employer is not listed in the approved employer site list, they will need to apply to determine if your practice site is eligible to participate in the program (i.e. host HPLRP participants). Sites can apply to host HPLRP providers at any time! Please complete the Rhode Island HPLRP Site Application and or reach out to us with questions.
Please mail all supporting documents to:
ATTN: Rebeca Vasquez / Manuel Ortiz
Office of Primary Care & Rural Health
Rhode Island Department of Health
3 Capitol Hill, Room 410
Providence, RI 02908
NOTE: The deadline to complete the online application and submit your supporting documents is February 28,2025. Supporting documents need to be delivered or postmarked by February 28, 2025.
Pursuant to Rhode Island General Law § 42-46-5 you are hereby notified that your application before the Rhode Island Health Professional Loan Repayment Program Board will be discussed during closed session; however, you may require that your application be discussed during open session. The information we collect in this application may be shared with other government entities for the administration of this program. This program is federally sponsored and the collection of information is used to fulfill the requirements of our federal grants.