Physician National Interest Waiver
Program Guidance
March, 2024
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Contents
Contact Information ....................................................................................................................... 2
Definitions ..................................................................................................................................... 3
General Information ...................................................................................................................... 4
Physician Nation Interest Waiver Overview .............................................................................. 4
Eligibility Criteria for A PNIW ..................................................................................................... 4
Attestation Process Overview ................................................................................................... 4
Requirements for an Attestation Letter ...................................................................................... 5
For Physicians who have Qualifying Prior Employment ............................................................ 7
Request Packet Instructions ....................................................................................................... 10
Attestation Letter Request Review Considerations ..................................................................... 11
Resources ................................................................................................................................... 13
Changes to Guidance ................................................................................................................. 14
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Contact Information
Cristie Duric
Primary Care Programs Manager
Iowa Department of Health and Human Services
Division of Public Health
321 E 12th St.
Des Moines, IA 50319
Phone: 515-229-3913
Email: [email protected]
Kevin Wooddell
Administrative Assistant II
Iowa Department of Health and Human Services
Division of Public Health
321 E 12th St.
Des Moines, IA 50319
Email: [email protected]
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Definitions
1. Health Professional Shortage Area (HPSA): An area, population group, or facility
designated by the U.S. Department of Health and Human Services as having an acute
shortage of primary health care professionals. Please refer to the resource at
https://data.hrsa.gov/tools/shortage-area for more information on HPSAs.
2. Mental Health Professional Shortage Area (MHPSA): An area designated by the U.S.
Department of Health and Human Services as having an acute shortage of mental
health care professionals.
3. Medically Underserved Area (MUA): An area designated by the U.S. Department of
Health and Human Services as meeting scoring criteria under the Index of Medical
Underservice (IMU) which considers the ratio of primary medical care physicians to
population, infant mortality rate, percentage of the population with incomes below the
poverty level, and percentage of the population age 65 or over. Please refer to the
resource at https://data.hrsa.gov/tools/shortage-area for more information on MUAs.
4. Medically Underserved Population (MUP): A designation by the U.S. Department of
Health and Human Services which involves application of the Index of Medical
Underservice (IMU) to data on an underserved population group within an area of
residence to obtain a score for the population group. Please refer to the resource at
https://data.hrsa.gov/tools/shortage-area for more information on MUAs.
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General Information
This guidance provides information about requirements of the Iowa Department of Health and
Human Services (Iowa HHS) to provide an attestation letter (statement of support) for a
Physician National Interest Waiver (PNIW).
PHYSICIAN NATION INTEREST WAIVER OVERVIEW
In accordance with the Nursing Relief for Disadvantaged Areas Act of 1999, national interest
waivers were established for foreign national physicians seeking a Green Card via the second-
preference employment category (EB-2). The EB-2 typically requires a job offer and labor
certification. A PNIW allows that requirement to be waived, but the physician must agree to work
full-time in a designated underserved area (Section 203(b)(2) of the Immigration Nationality Act
(INA). PNIWs are issued by the United States Citizenship and Immigration Services.
ELIGIBILITY CRITERIA FOR A PNIW
Criteria One
Agree to work full-time in a clinical practice for an aggregate of 5 years.
Criteria Two
Work in primary care (such as a general practitioner, family practice, general internist,
pediatrician, obstetrician/gynecologist, or psychiatrist) or be a specialty physician.
Criteria Three
Serve either in a Health Professional Shortage Area (HPSA), Mental Health Professional
Shortage Area (MHPSA – for psychiatrists only), a Medically Underserved Population (MUP), or
a Medically Underserved Area (MUA) for the entire service obligation period.
Criteria Four
Obtain a statement of support from a federal agency or a state department of health that the
clinical services that will be provided are in the public interest.
ATTESTATION PROCESS OVERVIEW
The State of Iowa is committed to improving access to health care in medically underserved
areas of the state. The PNIW is one way to address the shortage of physicians in Iowa. The
Primary Care Office, within the Division of Public Health at the Iowa HHS, receives requests for
and provides PNIW attestation letters. The PNIW program is voluntary and can be modified or
terminated at any time. The Iowa HHS is under no obligation to provide a letter of attestation.
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REQUIREMENTS FOR AN ATTESTATION LETTER
A U.S. health care facility or legal counsel must submit documentation on behalf of the
physician to the Iowa HHS to be considered for a PNIW attestation letter. The documentation is
collected to determine the term of the PNIW service obligation in Iowa, as well as to
substantiate physician qualifications and the claim that the work of the physician is in the public
interest.
Requirements are listed numerically and include a description, as necessary, and the
corresponding documentation required as part of the waiver request packet.
Requirement One
Employer must submit a statement in support of the physician.
Description
Include the following on employer statement:
1.1. Employer legal name and physical address
1.2. Employer point of contact
1.3. Physician legal name, date of birth, discipline, and specialty (if applicable)
1.4. Employment date of physician
1.5. Statement requesting the Iowa Health and Human Services act as an interested
government agency and provide an attestation letter for a PNIW
1.6. Full-time employment status (≥40 hours per week) providing patient care in a medically
underserved area (HPSA, MHPSA – for psychiatrists only, a MUP, or a MUA)
1.7. Each practice site where the physician will be fulfilling the service obligation (all sites must
be located in Iowa)
1.7.1. Practice site legal name and physical address
1.7.2. Hours providing patient care (at each practice site)
1.7.3. Designation (HPSA/MUA/MUP) type
1.7.4. Designation (HPSA/MUA/MUP) name
1.7.5. Designation (HPSA/MUA/MUP) ID
1.7.6. HPSA Score, as applicable
1.8. Brief description of services provided by the employer and all named practice sites
1.9. Commitment to employ the physician that meets one of the following
1.9.1. Five-year service obligation if no other qualifying previous employment
1.9.2. Balance of five-year service obligation if previous qualifying employment
NOTE: Regardless of the balance remaining on the service obligation, a
minimum 2-year service obligation is required in Iowa to be considered for an
attestation letter.
1.9.3. Iowa J-1 visa waiver recipients must have 1 year of service before applying for
PNIW
1.10. Impact of physician services on unmet healthcare needs of the medically underserved
community
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1.11. Accepts Medicaid, Medicare, uninsured, and medically indigent patients
1.12. Percent of medically underserved patients (Medicaid, Medicare, uninsured, and indigent)
the practice is or will be serving
1.13. Attempts to recruit qualified U.S. physicians and include (if position is not currently filled by
an Iowa-sponsored J-1 visa waiver recipient)
1.13.1. How long the position has been vacant
1.13.2. Method/s used to facilitate recruitment that were specifically for the position being
filled by the PNIW waiver requestor
1.13.3. The number of inquiries received as a result of recruitment methods
1.13.4. The number of physicians identified as a result of recruitment methods
1.13.5. How many interviews were conducted and if an offer was made
1.13.6. How many offers were made as a result of the recruitment efforts
1.13.7. How many offers were to U.S.-born physicians
Documentation
Signed and dated statement by the head of healthcare facility/employer on letterhead.
Requirement Two
Physician must submit an employment contract.
Description
The employment contract (including amendments or addendums) must have been executed
within 90 days of the date of request for an attestation letter. The contract/amended contract
must specify the following information, at minimum:
2.1. Employer legal name and physical address
2.2. All practice sites where the physician will be fulfilling service obligation (all sites must be
located in Iowa)
2.3. Physician legal name, specialty, and sub-specialty (if applicable)
2.4. Description of medical services provided
2.5. Commitment to employ the physician that meets the following, as applicable
2.5.1. Five-year service obligation if no other qualifying previous employment
2.5.2. Balance of five-year service obligation if previous qualifying employment
NOTE: Regardless of the balance remaining on the service obligation, a
minimum 2-year service obligation is required in Iowa to be considered for an
attestation letter.
2.5.3. Iowa J-1 visa waiver recipients must have 1 year of service before applying for
PNIW
2.6. Full-time employment status (≥ 40 hours per week) providing patient care in a medically
underserved area (HPSA, MHPSA – for psychiatrists only, a MUP, or a MUA)
2.7. Salary and benefits package.
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Documentation
2.8. Signed employment contract (or amended contract).
FOR PHYSICIANS WHO HAVE QUALIFYING PRIOR
EMPLOYMENT
Requirement Three
Physician must submit documentation of previous employment proposed to be applied toward
the PNIW five-year service obligation in Iowa.
Physicians with Previous Employment in Iowa
Previous employment that occurred in Iowa may be applied toward the fulfillment of the PNIW
five-year service obligation (for Iowa) as long as the eligibility criteria are met and supporting
documentation is submitted with the request packet.
Documentation
3.1. Signed letter(s), by an authorized representative, of employment confirmation on
letterhead from all previous employer(s) that contribute to the fulfillment of the 5-year
service obligation. The confirmation letter(s) from employer(s) must specify the following
information:
3.1.1. Employer legal name and physical address
3.1.2. Employer point of contact
3.1.3. Physician legal name, date of birth, discipline, and specialty (if applicable)
3.1.4. Employment period start date and end date
3.2. Each practice site where the physician worked toward the fulfillment of the service
obligation (all sites must be located in Iowa)
3.2.1. Practice site legal name and physical address
3.2.2. Hours providing patient care (at each practice site)
3.2.3. Designation (HPSA/MUA/MUP) type
3.2.4. Designation (HPSA/MUA/MUP) name
3.2.5. Designation (HPSA/MUA/MUP) ID
3.2.6. HPSA Score, as applicable
3.3. Full-time employment status (≥ 40 hours per week) providing patient care in a medically
underserved area (HPSA, MHPSA – for psychiatrists only, a MUP, or a MUA)
3.4. Impact of physician services on unmet healthcare needs of medically underserved
community
3.5. Accept Medicaid, Medicare, uninsured, and medically indigent patients
3.6. Percent of medically underserved patients (Medicaid, Medicare, uninsured, and indigent)
the physician served
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Iowa J-1 Visa Waiver Recipients
Service provided by a J-1 visa waiver recipient in Iowa may be applied toward the fulfillment of
the five-year service obligation (for Iowa) as long as supporting documentation is submitted with
the request packet.
NOTE: Iowa J-1 Visa Waiver recipients must have completed at least one year of the service
obligation before petitioning for a PNIW and must be in compliance with J-1 visa waiver
requirements.
Documentation
3.7. Copy of USCIS 212(e) J-1 waiver approval
3.8. Copy of most recently issued I-94 forms for physician and family members
3.9. Copy Physician Form DS-2019 “Exchange Visitor Program Certificate of Eligibility for
Exchange Visitor (J-1) status
Physicians with a PNIW Obligation from Another State
Time committed under a PNIW from another state may be applied toward the fulfillment of the
five-year service obligation (for Iowa) as long supporting documentation is submitted with the
request packet.
NOTE: Regardless of the balance remaining on the service obligation, a minimum 2-year
service obligation is required in Iowa to be considered for an attestation letter.
Documentation
3.10. Copy of PNIW attestation letter from each jurisdiction (state) where the service obligation
was being fulfilled.
3.11. Statement from State Health Department from each jurisdiction (state) where service
obligation was being fulfilled. The statement must be signed, on letterhead, and include:
3.11.1. Physician legal name, date of birth, discipline, and specialty (if applicable)
3.11.2. Physician employment was in the public interest
3.11.3. Employment start and end dates
3.11.4. Practice site locations
3.11.5. Confirmation that practice site locations were in a designated area
(HPSA/MUA/MUP) area
J-1 Visa Waiver Recipients of another State
Service provided by a J-1 Visa Waiver recipient of another state may request a PNIW (for Iowa)
as long as supporting documentation is submitted with the request packet and the physician is
compliant with J-1 Visa Waiver requirements.
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Documentation
3.12. Letter from the sponsoring state or entity. The letter must be signed, on official letterhead,
and include the following:
3.12.1. Physician legal name, date of birth, discipline, and specialty (if applicable)
3.12.2. Physician employment was in the public interest
3.12.3. Employment start and end dates
3.12.4. Practice site locations
3.12.5. Confirmation that practice site locations were in a designated (HPSA/MUA/MUP)
area
Requirement Four
Physician must be appropriately credentialed and qualified to practice in the state of Iowa.
Documentation
4.1. Copy of Curriculum Vitae
4.2. Proof of license includes one of the following
4.2.1. Copy of Iowa full/provisional professional license/certificate
4.2.2. Proof of application and payment to the Iowa Board of Medicine
4.2.3. Iowa Board of Medicine notification of status of license
Requirement Five
Physician must submit two letters of recommendation.
Description
Letters of recommendation, on official letterhead, must specify the following information and
come from professionals in a supervisory role to the physician
5.1. Name and title of the person making the recommendation
5.2. Physician name
5.3. Description of professional relationship
5.4. Physician qualities and experience
Documentation
5.5. Two signed letters of recommendation, on official letterhead, dated within 90 days of
request for attestation.
Requirement Six
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Physician has no other waiver requests pending with another government agency.
Documentation
Completed National Interest Waiver Attestation Request Terms and Conditions form.
Request Packet Instructions
PNIW attestation letter requests must be submitted in accordance with the following criteria.
Failure to submit as prescribed may result in a waiver support denial.
Use a Table of Contents and tab documents
Include a cover letter and indicate to whom the attestation letter should be addressed
Submit the documents in the order indicated on the Documentation Checklist
Request packet contents must be single-sided
Request packet contents must be on 8.5” x 11” paper
Do NOT use staples or binders
Do NOT include documents that are not required
Submit waiver request packet to:
Iowa HHS
Division of Public Health
Primary Care Office
Physician National Interest Waiver Program
321 E 12th St.
Des Moines, IA 50319
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Attestation Letter Request Review Considerations
PNIW Attestation Letter request review is based on the following considerations:
Review Consideration One
Contents are tabbed in accordance with the request packet instructions section.
Review Consideration Two
Requested information is sufficiently addressed.
Review Consideration Three
Program requirements are satisfied.
NOTE: PNIW attestation requests that do not meet requirements may be negotiated back for
clarification or additional, requested materials.
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PNIW Request Documentation Checklist
☐
Cover letter
☐
Signed letter from employer on letterhead
☐
Copy of signed employment contract (or amended contract)
☐
Signed letter(s) of employment confirmation on letterhead from all previous
employer(s) that contribute to the fulfillment of the PNIW 5-year service obligation
(if applicable)
☐
Copy of PNIW attestation letter from each jurisdiction (state) were PNIW service
obligation was being fulfilled (if applicable)
☐
Statement from State Health Department from each jurisdiction (state) where PNIW
service obligation was being fulfilled (if applicable)
☐
Curriculum Vitae
☐
Copy of Iowa full/provisional professional license or certificate or copy of proof of
payment to the Iowa Board of Medicine
☐
Two signed letters of recommendation on letterhead dated within 90 days of the
request for attestation
☐
Completed National Interest Waiver Attestation Request Terms and Conditions
form
☐
Additional Documentation for Physicians who are J-1 Visa Waiver Recipients
☐
Copy of USCIS 212(e) J-1 waiver approval (if applicable)
☐
Copy of most recently issued I-94 forms for physician and family members (if
applicable)
☐
Copy Physician Form DS-2019 “Exchange Visitor Program Certificate of Eligibility
for Exchange Visitor (J-1) status (if applicable)
☐
Completion of J-1 Visa Waiver service obligation statement from sponsoring state
(if other than Iowa, if applicable)
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Resources
1. Health Professional Shortage Areas: https://data.hrsa.gov/tools/shortage-area/hpsa-find
2. Immigration and Nationality Act: https://www.uscis.gov/legal-resources/immigration-and-
nationality-act
3. MUA/P Find: https://data.hrsa.gov/tools/shortage-area/mua-find
4. Shortage by Address: https://data.hrsa.gov/tools/shortage-area/by-address
5. Green Card Through a Physician National Interest Waiver: https://www.uscis.gov/green-
card/green-card-eligibility/green-card-through-a-physician-national-interest-waiver-niw
6. U.S. Citizenship and Immigration Services (USCIS) Conrad 30 Waiver Program:
https://www.uscis.gov/working-united-states/students-and-exchange-visitors/conrad-30-
waiver-program
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Changes to Guidance
Date of
Change
Section
Change
