New York State Department of Health Office of Primary Care and Health Systems

Management Center for Strategic Health Initiatives Office of Health Care Workforce Innovation

SFS Advertisement ID #PCSCRD8

Title: Solicitation of Interest #20820 – Primary Care Service Corps – Round 8

Agency: New York State Department of Health Office of Primary Care and Health Systems Management Center for Strategic Health Initiatives Office of Health Care Workforce Innovation

Contract Number: TBD

Contract Term: July 1, 2026 – June 30, 2029

Date of Issue: August 27, 2026

Questions Due: September 14, 2026 4:00 PM

Answers Posted: September 28, 2026 (on or about)

Due Date/Time: October 27, 2026 4:00PM

County(ies): Statewide

Location: Statewide

Classification: Medical & Health Care

Opportunity Type: Grant or notice of funds availability

I. Introduction The New York State Department of Health (Department) is issuing this Solicitation of Interest (SOI) under the Primary Care Service Corps (PCSC) Loan Repayment Program, which is modeled after the National Health Service Corps (NHSC). As set forth in Public Health Law (PHL) §§ 923 and 924, PCSC is a service-obligated loan repayment program that is designed to increase the supply of certain clinicians in underserved areas.

Clinicians eligible to apply under the program are:

• Dentists

• Dental Hygienists

• Nurse Practitioners (NP)

• Physician Assistants (PA)

• Certified Nurse Midwives (CNM)

• Clinical Psychologists

• Licensed Clinical Social Workers (LCSW)

• Licensed Marriage and Family Therapists

• Licensed Mental Health Counselors (LMHC)

Clinicians must commit to practice at an Active NHSC Approved Site. In addition, clinicians must demonstrate that they are or will be working in primary care or behavioral health and in an outpatient or other eligible setting as defined further herein.

Up to $504,990 in funding is available to support new awards under this SOI. Up to $72,000 is available for dentists (for full time practice), up to $54,000 is available for primary care clinicians (nurse practitioners, physician assistants and nurse midwives), and up to $36,000 is available for clinical psychologists, licensed clinical social workers licensed marriage and family therapists, licensed mental health counselors, and registered dental hygienists, not to exceed the amount of the individual’s qualifying educational debt, in return for a three-year commitment to practice at an NHSC Approved Site.

II. Minimum Qualifications Only dentists, dental hygienists, nurse practitioners, physician assistants, midwives, clinical psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed mental health counselors that meet the criteria set forth below are eligible to apply for PCSC funding through this Solicitation of Interest.

A clinician is eligible for a PCSC award for the period July 1, 2026 to June 30, 2029 to repay qualified educational debt if the following requirements are met:

1. The clinician must be a citizen of the United States or a permanent resident alien holding an I-155 or I-551 card.

2. The clinician must begin employment at the intended worksite on or before July 1, 2026.

3. The clinician must complete an Employment Letter using the format/text provided in Attachment 5: Employment Letter template. The Employment Letter must be on the employer’s letterhead, signed by an employee with the authority to represent the employer with respect to human resources matters, including the Human Resources Director, the Chief Executive Officer or the Chief Operating Officer.

4. The clinician must be licensed to practice in New York State at the time of application and attach and submit the appropriate license as Attachment 8.

Physician Assistants

Requirements: A current, full, permanent, unencumbered, unrestricted license and registration (pursuant to Education Law Article 131-B) to practice as a physician assistant (PA) in the State of New York. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health. PAs must provide primary care or behavioral health services - adult primary care, family primary care, pediatric, psychiatry, mental health, geriatrics, and women's health - to be eligible for PCSC.

Nurse Practitioners

Requirements: A current, full, permanent, unencumbered, unrestricted license and registration to practice as a registered nurse in the State of New York AND a certificate to practice as a nurse practitioner (pursuant to Education Law §6910) in the State of New York. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health. NPs must provide primary care or behavioral health services - adult primary care, family primary care, pediatric, psychiatry, mental health, geriatrics, and women's health - to be eligible for PCSC.

Certified Nurse Midwives

(pursuant to Education Law §6955) to practice as a licensed nurse midwife in the State of New York. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the Department.

Dentists

(pursuant to Education Law Article 133) to practice as a dentist in the State of New York in general or pediatric dentistry. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health. Only dentists who will provide general or pediatric dentistry are eligible for a PCSC award. Any time spent providing other services, such as endodontic, periodontics or orthodontic care, is ineligible for loan repayment funds.

Dental Hygienists

Requirements: A current, full, permanent, unencumbered, unrestricted license (pursuant to Education Law §6609) and registration to practice as a dental hygienist in the State of New York.

Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health. Only dental hygienists who will provide general or pediatric dental hygiene services are eligible for a PCSC award.

Psychologists

(pursuant to Education Law §7603) to practice as a psychologist in the State of New York.

Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health.

Licensed Clinical Social Workers

(pursuant to Education Law §7702) to practice as a clinical social worker in the State of New York. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health.

Licensed Marriage and Family Therapists

(pursuant to Education Law §8403) to practice as a marriage and family therapist in the State of New York. Applicants who have license applications pending with the New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health.

Licensed Mental Health Counselors

(pursuant to Education Law§ 8402) to as a licensed mental health counselor in the State of New York. Applicants who have license applications pending with the State of New York State Education Department may apply, but proof of licensure must be provided prior to entering into a contract for an award with the New York State Department of Health.

5. The clinician must be in good standing, meaning that such clinician:

a. Has not been excluded from or terminated by the federal Medicare or Medicaid programs (see http://www.omig.ny.gov);

b. For Physician Assistant Applicants Only: Has not been disciplined by the New York State Board for Professional Medical Conduct (see https://www.health.ny.gov/professionals/doctors/conduct/https://www.health.ny.gov/profession als/doctors/conduct);

c. For Applicants who are not Physician Assistants: Does not have an enforcement action from the New York State Board of Regents (see https//www.op.nysed/verification-search) Note: conduct rules are listed by profession at https://www.op.nysed.gov/title8/rules-board-regents/part-29

d. Is neither under indictment for, nor has been convicted of, any felony as defined by New York

State Penal Code.

Note: to determine if a crime is a felony:

• Go to this website: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO:

http://www.omig.ny.gov/ https://www.health.ny.gov/professionals/doctors/conduct/ https://www.health.ny.gov/professionals/doctors/conduct https://www.health.ny.gov/professionals/doctors/conduct http://www.op.nysed/verification-search) https://www.op.nysed.gov/title8/rules-board-regents/part-29 https://www.op.nysed.gov/title8/rules-board-regents/part-29 https://www.op.nysed.gov/title8/rules-board-regents/part-29 http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO

• Click on PEN (which is next to Penal)

• Click on the Article Number next to the crime in question (for example: Article 177 for Health Care Fraud)

• Click on the relevant sub-article (for example: 177.25 for Health Care Fraud in the first degree)

• The description will indicate if the crime is a misdemeanor or felony, and its class

(for example: Health Care Fraud in the first degree is a class B felony).

e. Has not had their professional clinical license revoked in any state or territory in the United States.

6. The clinician must not be in breach of a health professional service obligation to the federal government, any state government, or a local government.

7. The clinician must not have any judgment liens arising from debt to the federal government or any state government.

8. The clinician must not be fulfilling an obligation under any state or federal loan repayment program – including the Public Service Loan Forgiveness (PSLF) program -- which overlaps or coincides with the three-year PCSC service obligation.

9. On the date of award, the health care site where the clinician will be employed must be an NHSC

Active Site with a Health Professional Shortage Area (HPSA) score of 1 or more for the applicant’s professional discipline, as explained in Attachment 6, and evidenced by submission of Attachment 7.

10. The applicant must not have previously received, or currently be receiving, an award from the

Primary Care Service Corps.

11. If selected to receive a Primary Care Service Corps award, the applicant agrees to complete and submit participant surveys sent to them by the New York State Department of Health.

12. If applicant is selected to receive a Primary Care Service Corps award, the applicant’s employer agrees to complete and submit Employment Verification forms and Administrator surveys sent to them by the New York State Department of Health.

13. Clinicians must meet the following weekly hours of work requirements:

Except for FULL-TIME DENTISTS, clinical practice is defined as at least 20 hours per week for a minimum of 45 weeks per service year. The 20 hours per week may be compressed into no less than two work-days per week, with no more than 12 hours of work to be performed in any 24-hour period. Participants do not receive service credit for hours worked over the required 20 hours per week, and excess hours cannot be applied to any other work week. Time spent “on call” will not count towards the service requirement, except to the extent the provider is directly serving patients during that period.

For all health professionals, except as noted in bold below:

• At least 16 of the minimum 20 hours per week must be spent providing direct patient care in the outpatient ambulatory care setting(s) at the approved service site(s) specified in the clinician’s executed contract, during normally scheduled office hours.

• The remaining four (4) hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, in the approved service site(s) or providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s) or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) shall not exceed a total of four (4) hours of the minimum 20 hours per week.

For providers of geriatric services, behavioral health services, and certified nurse midwives:

• At least 11 of the minimum 20 hours per week must be spent providing direct patient care in clinician’s executed contract, during normally scheduled office hours.

• The remaining nine (9) hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, in the approved service site(s), or providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s) or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

For physician assistants, nurse practitioners, and certified nurse midwives serving in Critical Access Hospitals (CAHs):

• At least eight (8) of the minimum 20 hours per week much be spent providing direct patient care or teaching, mentoring or serving as a preceptor in the CAH-affiliated outpatient ambulatory care setting(s) specified in the clinician’s executed contract, during normally scheduled office hours.

• The remaining 12 hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, mentoring, or serving as a preceptor at the CAH’s skilled nursing facility or swing bed unit or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

For FULL-TIME dentists, clinical practice is defined as a minimum of 40 hours per week, for a minimum of 45 weeks each service year. The 40 hours per week may be compressed into no less than four (4) days per week, with no more than 12 hours of work to be performed in any 24-hour period. Participants do not receive service credit for hours worked over the required 40 hours per week, and excess hours cannot be applied to any other work week.

Also, time spent “on call” will not be counted towards the service requirement, except to the extent the provider is directly serving patients during that period:

• At least 32 of the minimum 40 hours per week must be spent providing direct patient care or teaching in the outpatient ambulatory care setting(s) at the approved service site(s) specified in the clinician’s executed contract, during normally scheduled office hours.

• The remaining eight (8) hours of the minimum 40 hours per week must be spent providing direct patient care or teaching, in the approved service site(s), providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s), or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed eight (8) hours of the minimum 40 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) at the approved service site shall not exceed eight (8) hours of the minimum 40 hours per week.

The following table summarizes the weekly hour requirements:

Table 1: Weekly Hour Requirements

Profession/ Setting

Max Patient

Care Onsite

Min Patient

Care Onsite

Max Patient

Care Offsite

Min Patient

Care Offsite

Max

Teach

Min

Teach

Max

Admin

Min

Admin

Min Week Total

All health professionals (including dentists) except as noted below

20 16 4 0 4 0 4 0 20

Geriatric Providers and Midwives

20 11 9 0 4 0 4 0 20

Geriatric Providers, Behavioral Health Providers, and Midwives

20 11 9 0 4 0 4 0 20

PAs, NPs, and Midwives at CAHs

20 8 12 0 4 0 4 0 20

Full Time Dentists

40 24 8 0 8 0 8 0 40

III. Project Narrative Up to $72,000 is available for dentists (for full time practice), up to $54,000 is available for primary care clinicians (nurse practitioners, physician assistants and nurse midwives), and up to $36,000 is available for clinical psychologists, licensed clinical social workers licensed marriage and family therapists, licensed mental health counselors, and registered dental hygienists not to exceed the amount of the individual’s qualifying educational debt, in return for a three-year commitment to practice at an NHSC Approved Site referenced herein as the “PCSC service obligation period”. To be considered for funding, applicants must meet the eligibility requirements outlined in Section II (Minimum Qualifications).

A. Use of Funds

One hundred percent of PCSC Award funds must be applied to qualified educational debt.

For purposes of this SOI, “qualified educational debt” means any outstanding amounts remaining on student loans that were used by the clinician to pay graduate or undergraduate tuition or related educational expenses, where such loans were made by or guaranteed by the federal or state government or made by a lending or educational institution approved under Title IV of the federal Higher Education Act. Applicants must include educational loan statements dated no more than 30 days prior to submission (to be uploaded as Attachment 3). Such statements may be forwarded to the New York State Higher Education Services Corporation (HESC) to verify the existence and amount of qualified education debt. Applicants must complete Attachment 4 to give consent for HESC to disclose any loan information to the Department. No PCSC award shall be made in excess of the outstanding amount of educational debt as verified by HESC.

Awardees will be required to submit educational loan statements within 60 days of award payment to ensure that payments were applied to qualified educational loans.

Please note: Awardees are not permitted to hold their Primary Care Service Corps grant contract payments in private accounts for an extended period of time. All contract disbursements must be applied to the pre-approved outstanding educational debt by the earlier of (a) the first date following grant disbursement upon which an installment payment is owed by the Awardee on the pre-approved educational debt, or (b) sixty (60) days after the date of the grant disbursement, whichever comes first. In any event, Awardees must provide the New York State Department of Health with proof of the application of the full amount of the grant disbursement to the pre-approved educational payment no later than sixty (60) days prior to the next scheduled grant disbursement. If you are not able or willing to apply these funds, you may be required to return all prior disbursements of grant funds not applied to the repayment of eligible student loan debt to the State. The New York State Department of Health will not be able to disburse any future funds until educational loan repayment statements verifying that prior funds have been applied are received.

A. Application Limits

No more than one application will be accepted from a single clinician. If a clinician submits more than one application, the last application submitted shall supersede all previous submissions. In such case, the email time stamp date of the last application submitted shall be considered the application submission time. The previously submitted applications will not be reviewed or considered.

B. Award Limits

The award limit for the Primary Care Service Corp Loan Repayment Program for primary care providers is $36,000 for a three-year contract, unless the awardee is a nurse practitioner, physician assistant or nurse midwife, in which case the award limit is $56,000, or a full time dentist, in which case the award limit is $72,000 for a three-year contract.

C. Default

There are significant financial consequences in the event a clinician fails to complete their three-year Primary Care Service Corps service obligation. The default penalties are provided in Attachment 9 – Default Penalty Attestation.

In the event that the Applicant, through any cause, fails to perform any of the terms, covenants or promises of any contract resulting from this SOI, the Department, acting for and on behalf of the

State, shall thereupon have the right to terminate the contract by giving notice in writing of the fact and date of such termination to the Applicant.

D. Contract Modifications

Awardees may be permitted to change the service location of the contract, or defer the PCSC service obligation period, as described below.

1. Change of Location:

Obligated clinicians are permitted to change their service locations, provided that:

1) the clinician interested in changing locations notifies the Department in writing prior to the change;

2) the new service location is an NHSC Active site in York State with a HPSA score of 1 or more in the awardee’s professional discipline; and

3) the Department approves the change prior to the awardee changing job sites.

4) If the site change is approved by the Department, an Attachment 5 – Employment Letter for the new work site(s) must be submitted by the appropriate administrator of the new work site(s) within 30 days of execution of the employment contract.

2. Request to Defer Obligation:

• Clinicians who request to defer their PCSC service obligations for reasonable cause may submit a request in writing to the Department.

• Examples of reasonable cause may include: parental leave, personal or family illness, military service, etc.

• The decision to permit a deferral will be solely at the discretion of the Department.

• Any deferral period granted by the Department will be added to the obligated practitioner’s term obligation.

IV. How to Apply Written questions will be accepted until 4:00 p.m. on September 14, 2026. All questions should be submitted electronically to the email address: sch_loan@health.ny.gov. All questions should be submitted with the subject line “PCSC Round 8 Question”. In the event that any updates and/or clarification of information is warranted, information will be posted in the Contract Reporter under the tab “Documents” for this announcement. Responses to all questions received by September 14, 2026, will be posted on or about September 28, 2026.

Late Applications Will Not Be Accepted.

It is the Applicant’s responsibility to ensure that all materials included in the application have been properly prepared and submitted. The application consists of the completed Attachments 1-10 listed below. You must submit ONE EMAIL with each required Attachment as its own pdf file attachment.

Make sure to name each document accordingly (i.e. Attachment 1, Attachment 2). Applications must be submitted via email to sch_loan@health.ny.gov no later than 4:00 pm ET on the date posted on the cover of this SOI. Again, all application documents should be submitted together as attachments in ONE EMAIL.

mailto:sch_loan@health.ny.gov

Attachments

The following attachments (1-10) include both reference materials and items that must be completed and submitted as the PCSC application for this SOI. If you cannot complete Attachment 1 successfully, do not continue any further; you are not an eligible applicant for the PCSC program.

Items in Attachment 6 will require supporting documentation. This documentation will be required for all applicants to justify that the clinicians will be working in an underserved area. All mandatory attachments must be completed to have your application be reviewed for a PCSC award.

Attachment 1: Minimum Eligibility Requirements (mandatory) Attachment 2: Program Specific Questions (mandatory) Attachment 3: Loan Statements (mandatory) Attachment 4: Consent to Disclosure (mandatory) Attachment 5: Employment Letter (mandatory) Attachment 6: Tool to Identify Eligible Sites (for reference only) Attachment 7: Site Information (mandatory) Attachment 8: Current Professional Licenses (mandatory) Attachment 9: Default Penalty Attestation (mandatory) Attachment 10: Tax Issues (for reference only)

Review & Award Process

Applications meeting the guidelines and having submitted all mandatory Attachments will be reviewed and evaluated by the Department. Applications will be evaluated on a Pass/Fail basis.

Department staff will review applications in the order in which they are received.

The Department will notify an applicant by email if the application is complete or incomplete. If the application is complete, no further action by the Applicant is needed. If the application is incomplete, the Department will provide the applicant a list of outstanding items. The applicant will have one opportunity to supply the missing information within 10 business days of being notified by the Department via email. All missing information must be emailed to: sch_loan@health.ny.gov. If the applicant fails to respond to the missing information request within this time period, the application will not be processed any further and will not be funded. Because of this, it is advantageous to submit a complete application, and to respond to the Department’s email regarding any omissions, as soon as possible. The due date will be clearly stated in the communication from the Department advising that the application is incomplete. No additional information will be accepted after this due date.

Funding for this project is contingent on the availability of funding and the number of eligible applicants that respond to the advertisement. Available funding to support this initiative will be limited to the amount(s) appropriated in the enacted State Fiscal Year budgets for this purpose. This advertisement is not a guarantee or promise of funding.

The pool of complete and eligible applications will be awarded in order of the postmark date of the valid application until available funding is exhausted. When funding has been depleted to a level such that an Applicant’s total requested funding amount cannot be met, the Applicant will be offered a reduced award amount. If the Applicant accepts that amount, no further awards will be made. If the Applicant declines that amount, the next eligible Applicant will be offered an award until funds are completely exhausted. The Department reserves the right to allocate funding in ways to best serve the interests of the State.

The Department of Health, acting at the discretion of the Commissioner of Health, reserves the right to postpone, change, or waive the service obligation and/or payment amounts in individual circumstances where there is a compelling need or hardship due to circumstances beyond the control of the Contractor which causes or is likely to cause the Contractor to default in the performance/completion of their service obligation under their contract.

The Department anticipates that awards will be announced in December 2026. Awardees will have a PCSC contract start date of July 1, 2026.

Contact Information

Primary contact: Dorota Kearney Office of Workforce Innovation New York State Department of Health Corning Tower, Room 1695 Albany, New York 12237 sch_loan@health.ny.gov

Submit to contact: Dorota Kearney Office of Workforce Innovation New York State Department of Health Corning Tower, Room 1695 Albany, New York 12237 sch_loan@health.ny.gov

ATTACHMENT 1

Minimum Eligibility Requirements

Solicitation of Interest # 20820

Applicant Name:

Primary Care Service Corps (PCSC) Loan Repayment Program

Instructions: The Clinician who is completing the PCSC service obligation is eligible to participate in this program only if they can answer “Yes” to questions (1-12). Applicants are instructed to upload the completed document as Attachment 1 of the application.

1. You are a U.S. citizen or a permanent resident alien holding an I-155 or I-551 card.

YES NO

2. You will be employed at the intended worksite on or before August 1, 2025.

YES NO

3. You submitted an Employment Letter (Attachment 5) signed by authorized administrator.

YES NO

3a.

Employment Letter (Attachment 5) includes the appropriate CLASSIFICATION STATEMENT, and the text of the CLASSIFICATION STATEMENT has not been altered.

YES NO

3b.

If you indicated your profession as Physician Assistant, then Employment Letter includes sentence: “The clinician is a physician assistant, and their primary practice area will be in adult medicine, family medicine, pediatrics, psychiatry, mental health, geriatrics or women’s health.”

YES NO Not Applicable

3c.

If any of your Intended Worksites are School Based Clinics, then the Employment Letter includes the sentence: “The clinician will be serving at a School Based Health Center and will be primarily engaged in direct clinical and counseling services, and clinician will meet clinical practice requirements for entire calendar year.”

YES NO Not Applicable

4. You are currently licensed to practice your profession in New York State.

YES NO

4a.. You have Included a copy of a current, full, permanent, unencumbered, unrestricted license and registration to practice your profession in the State of New York.

YES NO

4b. If you are a Nurse Practitioner, you have included a copy of a current, full, permanent, unencumbered, unrestricted license and registration to practice as a registered nurse in the State of New York AND a certificate to practice as a nurse practitioner in the area of adult health, family health, gerontology, pediatrics, psychiatry, or women's health OR proof of pending license and/or registration and/or certification.

YES NO Not Applicable

5a. You have not been excluded from or terminated by the federal Medicare or Medicaid programs (see http://www.omig.ny.gov).

TRUE FALSE

5b. If you are a Physician Assistant, you have not been disciplined by the New York State Board for Professional Medical Conduct (see https://www.health.ny.gov/professionals/doctors/conduct).

TRUE FALSE

5c. If you are not a Physician Assistant, you do not have an enforcement action from the New York State Board of Regents

TRUE FALSE

5d. You are neither under indictment for, nor have you been convicted of, any felony as defined by New York State Penal Code. To determine if a crime is a felony:

• Go to this website: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO:

• Click on PEN (which is next to Penal)

• Click on the Article Number next to the crime in question (for example: Article 177 for Health Care Fraud)

• Click on the relevant sub-article (for example: 177.25 for Health Care Fraud in the first degree)

• The description will indicate if the crime is a misdemeanor or felony, and its class

(for example: Health Care Fraud in the first degree is a class B felony).

TRUE FALSE

http://www.omig.ny.gov/ https://www.health.ny.gov/professionals/doctors/conduct http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO

5e. You have not had your professional clinical license revoked in any state or territory in the United States.

TRUE FALSE

6. You are not in breach of a health professional service obligation to the federal government, any state government, or a local government.

TRUE FALSE

7. You do not have any judgement liens arising from debt to the federal government or any state government.

TRUE FALSE

8. You are not fulfilling an obligation under any state or federal loan repayment or forgiveness program (including, but not limited to: the National Health Service Corps, the New York State Primary Care Service Corps, the Public Service Loan Forgiveness Program, the Indian Health Service Loan Repayment, the New York State Licensed Social Worker Loan Forgiveness Incentive Program) which overlaps or coincides with the three-year PCSC service obligation period of July 1, 2026 to June 30,2029

TRUE FALSE

9a. All your intended worksites are Active NHSC Sites according to the HRSA Health Workforce Connector Website at: https://connector.hrsa.gov/connector/

TRUE FALSE

9b. All your intended worksites each have HPSA scores greater than zero for your professional discipline (primary care or dental or mental health) according to the HRSA Health Workforce Connector Website at: https://connector.hrsa.gov/connector/

TRUE FALSE

10. You have not previously received, nor are currently receiving, an award from the Primary Care Service Corps.

TRUE FALSE

11. If you receive a Primary Care Service Corps award, do you agree to complete and submit participant surveys sent to you by the New York State Department of Health?

YES NO

12. Employment Letter (Attachment 5) indicates that if you receive a Primary Care Service

Corps award, your employer agrees to complete and submit Employment Verification https://connector.hrsa.gov/connector/ forms and Administrator Surveys relating your worksite(s),and agrees to notify the Department of Health in the event of your termination or separation.

TRUE FALSE

13. Employment Letter (Attachment 5) indicates that you will work for at least 20 clinical hours per week for 45 weeks per year.

TRUE FALSE

ATTACHMENT 2

Program Specific Questions

Instructions: Respond to each of the questions in all sections described below when completing the Program Specific Questions. All questions require an answer, and you must ensure all answers are legible. Only questions marked with an asterisk (*) may be answered “Not Applicable”. Applicants are instructed to upload the completed document as Attachment 2 of the application.

1 First Name 2 Middle Name* 3 Last Name 4 Prefix (Dr., Mr., Ms., Mrs., Mx., etc.)*:

5 Profession:

6 Sub-Specialty* 7 HPSA Discipline Class (Primary Care or Mental Health or

Dental) for your Profession

8 Are you applying as a Full-Time Dentist*?:

9 National Provider Identification (NPI) Number:

10 New York State Professional License Number:

11 How many different sites will you be practicing at while fulfilling their PCSC service obligation:

12 Employer (Corporate Operator) of Intended Worksite #1.

13 Site Name and Address of Intended Worksite #1:

14 Number of Weekly Work Hours at Intended Worksite #1:

15 Name of Supervisor at Intended Worksite #1:

16 Work Email address of Supervisor at Intended Worksite #1:

17 Employer (Corporate Operator) of Intended Worksite #2*.

18 Site Name and Address of Intended Worksite #2*:

19 Number of Weekly Work Hours at Intended Worksite #2*:

20 Name of Supervisor at Intended Worksite #2*:

21 Work Email address of Supervisor at Intended Worksite #2*:

22 Employer (Corporate Operator) of Intended Worksite #3*:

23 Site Name and Address of Intended Worksite #3*:

24 Number of Weekly Work Hours at Intended Worksite #3*:

25 Name of Supervisor at Intended Worksite #3*:

26 Work Email address of Supervisor at Intended Worksite #3*:

26 Maiden Name*:

28 Home Street Address:

29 Home City:

30 Home State:

31 Home ZIP:

32 Email Address where correspondence and information about

PCSC should be sent:

33 Work Email Address:

34 Home Telephone Number:

35 Cellular Telephone Number*:

36 Please list any other loan repayment programs (including, but not limited to: the National Health Service Corps, Indian Health Service Loan Repayment, New York State Licensed Social Worker Loan Forgiveness Incentive Program, Public Service Loan Forgiveness Program) for which you have an application pending.

37 Current amount of eligible student loan debt (round down to nearest whole dollar). Please upload, as Attachment 3 under Pre-Submission Uploads, loan balance statements for all current loan debt for undergraduate or graduate education, made by or guaranteed by the federal or state government, or made by a lending or educational institution approved under Title IV of the Federal Higher Education Act.

38 Amount of funding requested from PCSC:

39 Worksite(s) on July 1, 2026. Corporate Operator, Site

Name(s), Address(es):

ATTACHMENT 3 (Mandatory)

Loan Statements For Qualified Educational Debt

Please note this document is a placeholder as loan statements will vary among applicants.

Applicants are instructed to upload the most current Loan Statements for qualified educational debt* as Attachment 3.

These statements should be no greater than (30) days prior to the date on which the application is submitted.

The Loan Statements must show, at a minimum, the following information:

• Evidence of Statement Authenticity (letterhead or statement banner with credit corporation logo)

• Creditor Name

• Applicant Name

• Loan Number

• Loan Statement Date

• Loan Balance

* Qualified educational debt is defined in Section III.A. Use of Funds of this SOI.

ATTACHMENT 4

Consent to Disclosure

Instructions: Applicants are instructed to upload the completed Consent to Disclosure document as Attachment 4 of the application.

I authorize and provide my consent for any lender, servicer, the U.S. Department of Education, any servicer for the U.S. Department of Education, or other institution or individual to disclose to NYS Higher Education Services Corporation (HESC) any information relevant to HESC’s review and consideration of my outstanding student loan debt. I give HESC permission to contact and disclose my personal information to any lender, servicer, U.S. Department of Education, any servicer for the U.S. Department of Education, or other institution or individual to facilitate HESC’s review and consideration of my outstanding student loan debt. I give HESC permission to share my personal information with its agents, business partners, other State and/or federal agencies, and other institutions or individuals necessary for the purpose of evaluating my student loan debt. I give HESC permission to use whatever means it deems necessary to verify any information I have provided, or will provide, to be used for the purpose of evaluating my student loan debt, including but not limited to, documentation submitted or accessed through other parties.

Applicant’s Name (Print)

Applicant’s Signature

Date

ATTACHMENT 5 (Mandatory Upload)

Employment Letter Template

(EMPLOYER LETTERHEAD)

(Date)

Dear Primary Care Service Corps Administrator:

It is mutually understood that (clinician name) intends to fulfill a NYS Primary Care Service Corps service obligation with (name of employer) during the period July 1, 2026 to June 30, 2029.

During that time, (clinician name) will be assigned to:

• (name and address of work site) which is a National Health Service Corps Active Site, for

% of his/her time. (Note: add additional worksite bullets if there are multiple worksites, the total should equal 100%)

They will work as a (clinical title and specialty) for approximately clinical hours per week for weeks per year during that time.

(For clinicians serving at School Based Health Centers only) {The clinician will be serving at a School Based Health Center and will be primarily engaged in direct clinical and counseling services, and clinician will meet clinical practice requirements for entire calendar year.}

(For Physician Assistants only) {The clinician is a physician assistant, and their primary practice area will be in adult medicine, family medicine, pediatrics, psychiatry, mental health, geriatrics or women’s health.}

(Insert the Appropriate CLASSIFICATION STATEMENT from list below. Please select the appropriate bracketed term to describe your employee. Do not alter any other text in the statement.)

If the applicant receives Primary Care Service Corps award, (name of employer) agrees to complete and submit Employment Verification forms and Administrator Surveys relating to the applicant and their worksite(s),and agrees to notify the Department of Health in the event of termination or separation of the employee applicant.

Sincerely, (Signature)

(Title of Signatory)

CLASSIFICATION STATEMENTS

As a {physician assistant} {nurse practitioner} {dentist} {dental hygienist} serving at a {primary care} / {dental} facility, this clinician will work at least 20 hours per week (not to exceed 39 hours per week), for a minimum of 45 weeks per service year. The 20 hours per week may be compressed into no less than two workdays per week, with no more than 12 hours of work to be performed in any 24-hour period. In addition, it is understood that:

• At least 16 of the minimum 20 hours per week must be spent providing direct patient care in clinician’s executed contract, during normally scheduled office hours.

• The remaining four (4) hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, in the approved service site(s) or providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s),or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Participants do not receive service credit for hours worked over the required 20 hours per week, and excess hours cannot be applied to any other work week. Full-time work done by a half-time participant will not change the participant’s half-time status and will not entitle the clinician to full-time service credit. Also, time spent “on call” will not count towards the service requirement, except to the extent the provider is directly serving patients during that period.

As a {certified nurse midwife} {physician assistant providing geriatric services} {nurse practitioner providing geriatric services}, this clinician will work at least 20 hours per week (not to exceed 39 hours per week), for a minimum of 45 weeks per service year. The 20 hours per week may be compressed into no less than two workdays per week, with no more than 12 hours of work to be performed in any 24-hour period. In addition, it is understood that:

clinician’s executed contract, during normally scheduled office hours.

• The remaining nine (9) hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, in the approved service site(s), or providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s) or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Participants do not receive service credit for hours worked over the required 20 hours per week, and excess hours cannot be applied to any other work week. Full-time work done by a half-time participant will not change the participant’s half-time status and will not entitle the clinician to full-time service credit. Also, time spent “on call” will not count towards the

As a {physician assistant} {nurse practitioner} {clinical psychologist} {licensed clinical social worker} {licensed marriage and family therapist} {licensed mental health counselor} providing behavioral health services, this clinician will work at least 20 hours per week (not to exceed 39 hours per week), for a minimum of 45 weeks per service year. The 20 hours per week may be compressed into no less than two workdays per week, with no more than 12 hours of work to be performed in any 24-hour period. In addition, it is understood that:

clinician’s executed contract, during normally scheduled office hours.

• The remaining nine (9) hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, in the approved service site(s), or providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s), or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Participants do not receive service credit for hours worked over the required 20 hours per week, and excess hours cannot be applied to any other work week. Full-time work done by a half-time participant will not change the participant’s half-time status and will not entitle the clinician to full-time service credit. Also, time spent “on call” will not count towards the service requirement, except to the extent the provider is directly serving patients during that period.

As a {physician assistant} {nurse practitioners} {certified nurse midwife} serving at a Critical Access Hospital (CAH), this clinician will work at least 20 hours per week (not to exceed 39 hours per week), for a minimum of 45 weeks per service year. The 20 hours per week may be compressed into no less than two workdays per week, with no more than 12 hours of work to be performed in any 24-hour period. In addition, it is understood that:

• At least eight (8) of the minimum 20 hours per week much be spent providing direct patient care or teaching, mentoring, or serving as a preceptor in the CAH-affiliated outpatient ambulatory care setting(s) specified in the Clinician’s executed contract, during normally scheduled office hours.

• The remaining 12 hours of the minimum 20 hours per week must be spent providing direct patient care or teaching, mentoring, or serving as a preceptor at the CAH’s skilled nursing facility or swing bed unit, or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) shall not exceed a total of four (4) hours of the minimum 20 hours per week.

• Participants do not receive service credit for hours worked over the required 20 hours per week, and excess hours cannot be applied to any other work week. Full-time work done by a half-time participant will not change the participant’s half-time status and will not entitle the clinician to full-time service credit. Also, time spent “on call” will not count towards the

As a FULL-TIME dentist serving at a dental facility, this clinician will work a minimum of 40 hours per week, for a minimum of 45 weeks each service year. The 40 hours per week may be compressed into no less than four (4) days per week, with no more than 12 hours of work to be performed in any 24-hour period. In addition, it is understood that:

• At least 32 of the minimum 40 hours per week must be spent providing direct patient care or teaching in the outpatient ambulatory care setting(s) at the approved service site(s) specified in the clinician’s executed contract, during normally scheduled office hours;

• The remaining eight (8) hours of the minimum 40 hours per week must be spent providing direct patient care or teaching, in the approved service site(s), providing direct patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved service site(s), or performing practice-related administrative activities.

• Practice-related administrative activities shall not exceed eight (8) hours of the minimum 40 hours per week.

• Teaching (which includes mentoring and serving as a preceptor) at the approved service site shall not exceed eight (8) hours of the minimum 40 hours per week.

• Participants do not receive service credit for hours worked over the required 40 hours per week, and excess hours cannot be applied to any other work week. Also, time spent “on call” will not be counted towards the service requirement, except to the extent the provider is directly serving patients during that period.

ATTACHMENT 6

Proof of Site Eligibility

Instructions: Primary Care Service Corps awardees must be employed at National Health Service Corps Active Sites, and the site must have a HPSA score of 1 or more for the awardee’s professional discipline (primary care or dental or mental health)

To verify that a site is a National Health Service Corps Approved Site:

1. Go to this website: https://connector.hrsa.gov/connector/

2. In the Search dialog box, click on the Sites radio button (blue dot will appear in circle next to word Sites)

3. In the Location box, enter the name of the town, and then click on the choice that appears in the drop box (to see all sites in New York State, choose: “New York USA”).

4. Press the [Search] Button.

5. A list of all NHSC Approved Sites in New York State (centered on the requested town) will appear in the Search Results on the Site tab.

6. Use the scroll bar to scroll through the Search Results list to find the intended work site.

7. If the right column of the Search Results for the intended site shows the words “NHSC Active”, or “NHSC/Nurse Corps Active” or NHSC/Nurse Corps/STAR Active” then the site is an NHSC Active Site.

8. Click on the name of the site to activate the link and display site details.

9. Verify that the address of the site is the address of the intended site (some site names are vague, so please check that you have found the correct site).

10. Verify that the NHSC HPSA score (top right corner of screen) for the applicant’s professional discipline (primary care or dental or mental health) is 1 or more. If the NHSC HPSA score shows “NA” for the applicant’s discipline, then this site is NOT an allowable worksite for the applicant.

11. Print the screen (or save screenshot as a PDF) showing site name, site address and site

HPSA scores, and submit with the application as Attachment 8 Site Information.

12. Repeat steps above for each intended worksite.

The…