State of Illinois
Department of Public Health
State 30 J-1
Visa Waiver Program
Revised September 2022
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 2
STATE OF ILLINOIS
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
J-1 VISA WAIVER PROGRAM
Under the requirements of the Illinois Freedom of Information Act [5 ILCS 140], all
information submitted in support of the J-1 Visa Waiver application, including the
employment contract, becomes public record and may be released to the public unless
otherwise indicated. Those sections of the application that are confidential or contain
proprietary information must be stamped as confidential and include the basis for the
confidential claim, in order to protect the record. However, a court may conclude that
any records submitted in this process should be disclosed upon request.
Overview
Below is the Illinois Department of Public Health’s (IDPH) application process for the J-1 Visa
Waiver Program. The IDPH’s policies are also at 77 Ill. Adm. Code 591
(http://www.ilga.gov/commission/jcar/admincode/077/07700591sections.html).
Amended Sections for Visa Waiver Program for International Medical Graduates (77 Ill. Adm.
Code 591), contained in emergency rules that were effective September 19, 2022, are
applicable to the October 2022 application cycle and subsequent implementation in addition to
the Title 77, Part 591 Sections that were not amended.
Purpose, Authority, and Scope
The Immigration and Nationality Technical Corrections Act of 1994 (P.L. 103-416) amended the
provision of the Immigration and Nationality Act (Act) on the two-year foreign residence
requirement affecting applicants. These applicants were admitted to the U.S. on a J visa, or
acquired such status after admission to the U.S., and must return to the country of their
nationality or country of last legal residence upon the completion of their participation in an
exchange visitor program.
The U.S. Department of Homeland Security, Citizenship, and Immigration Service (USCIS) may
waive the two-year home country requirement upon the recommendation of the U.S.
Department of State, Waiver Review Division (USDOS). The Act authorizes IDPH to request the
USDOS to recommend that USCIS grant the waiver.
The applicant must demonstrate that he/she has an offer of full-time employment, will begin
employment within 90 days of receiving a waiver, and will work for at least three years at a
medical facility in an area designated by the U.S. Department of Health and Human Services as
having a shortage of health care professionals.
A waiver will not be granted unless the country to which the applicant is contractually obligated
to return furnishes USDOS with a written statement that it has no objection to the waiver. State
departments of health can request applicants sign a certification statement indicating presence
or absence of a contractual obligation to their home country or country of last legal residence.
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 3
Physicians
The program accepts applications from all medical specialties. Physicians who apply for a
waiver shall:
1) For primary care physicians, have entered into an employment contract with a
medical facility located in a Primary Care Health Professional Shortage Area
(HPSA). If the physician will work at more than one medical facility, each facility
shall be located in a Primary Care HPSA.
2) For psychiatrists, have entered into an employment contract with a medical facility
located in a Mental Health HPSA. If the psychiatrist will work at more than one
medical facility, each facility shall be located in a Mental Health HPSA.
3) For specialists, have entered into an employment contract with a medical facility
located in a Primary Care HPSA. If the specialist will work at more than one medical
facility, each facility shall be located in a Primary Care HPSA.
4) For specialists who apply for the J-1 visa waiver flex option, have entered into an
employment contract with a medical facility that is not in an HPSA, Medically
Underserved Area (MUA) or Medically Underserved Population (MUP).
5) Be board eligible or board certified in his/her medical specialty.
6) Have completed a residency in his/her medical specialty.
Medical Facilities
Medical facilities shall:
1) Meet the definition of medical facility (see 77 Ill. Adm. Code 591.20).
2) For primary care physicians, be located in a Primary Care HPSA.
3) For psychiatrists, be located in a Mental Health HPSA.
4) For specialists, be located in a Primary Care HPSA.
5) For specialist who apply for the J-1 visa waiver flex option, not be located in a HPSA,
MUA, or MUP.
6) Be in good standing with the Illinois Secretary of State (see 77 Ill. Adm. Code
591.100(b)(6) and 591.120(b)(2)).
Employers of the medical facility shall not be a relative of the applicant (i.e., spouse, parent,
sibling, or child).
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 4
Processing Fee
A processing fee of $3,000 shall accompany each application submitted to IDPH (see 77 Ill.
Adm. Code 591.115(a)). Payment shall be by check or money order payable to the Illinois
Department of Public Health. If the payment does not accompany the application, it will be
deemed incomplete. IDPH will take no action on the application until the fee has been received.
If the payment is not valid due to insufficient funds or other reasons, the application will be null
and void. Fee payments are not refundable.
Submission Time Frames
Applications are accepted between October 1 and October 31 of each year. If all
recommendations are not made from the applications received in October, applications will be
accepted between January 1 and January 31 and between April 1 and April 30, if necessary.
Applications will not be accepted after the submission deadlines.
Submission means an application has been received by IDPH by the submission deadline.
Submission does not mean that an application is postmarked by the submission deadline but
arrives at IDPH on a later date.
Application Package
The application shall include the following in the order listed below:
1. A statement from the administrator of the medical facility describing prior recruitment
difficulties experienced by the medical facility, the expected practice arrangement for the
physician, and the impact on the medical facility and the patients it serves if the waiver is
not approved.
2. A copy of the medical facility's Certificate of Good Standing from the Illinois Secretary of
State.
3. Documentation of the medical facility's payment policy demonstrating that the physician
will accept Medicare/Medicaid patients and will not deny services to anyone because of
an inability to pay.
4. A copy of the employment contract between the physician and the medical facility.
A) The contract shall include:
i) The name and address of the medical facility.
ii) The specific geographic area(s) in which the physician will practice.
iii) A statement that the contract is for a minimum three year duration.
iv) A statement that the physician will practice full-time (40 hours per week).
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 5
a) For primary care physicians, the statement shall include that the
physician will work in the Primary Care HPSA.
b) For psychiatrists, the statement shall include that the physician will
work in the Mental Health HPSA.
c) For specialists, the statement shall include that the physician will
work in the HPSA, MUA or MUP. If the medical facility is not in a
HPSA, MUA or MUP, the application shall document that at least
51% of the physician's patients come from a HPSA, MUA, or
MUP.
d) A statement that any amendments to the contract will adhere to
State and federal J-1 visa waiver requirements.
e) A statement that termination of the physician may be only for
cause.
f) A statement that the physician will begin working within 90
calendar days after receiving the waiver and employment
authorization from USCIS.
g) A list of benefits and insurance to be provided to the physician.
B) The employment contract shall not include:
i) A non-compete clause.
ii) A liquidated damages clause.
C) If the physician will work at multiple facilities, the contract must contain the
above-referenced information for each facility.
5. A statement from the medical facility that the salary or other form of financial support
offered to the physician is equivalent to that offered to all other physicians with similar
skills and experience recruited by the medical facility.
6. A letter from the chief medical officer or other high level hospital executive verifying that
hospital admitting privileges will be granted to the physician and, if not, how admissions
of the physician's patients will be arranged. If the physician will work at multiple
hospitals, each hospital must submit this letter in the application.
7. A letter from at least one local organization or agency, such as the chamber of
commerce, local health department, or other community-based organization,
demonstrating support for the physician.
8. A copy of the applicant's Illinois medical license or application for an Illinois medical
license.
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 6
9. A copy of the applicant's completed U.S. Department of State, J-1 Visa Waiver
Recommendation Application (DS-3035)
10. A copy of the applicant's curriculum vitae.
11. A copy of the IAP-66/DS-2019 Form (Certificate for Exchange Visitor J-1 Status) for
each year the applicant was in J-1 status.
12. Copies of the applicant's U.S. Customs and Border Protection I-94 Entry and Departure
Cards.
13. Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative (if
applicable).
14. A personal statement from the applicant regarding his/her reasons for not wishing to
fulfill the two-year country of nationality or country of legal residence requirement.
15. For specialists, documentation that a shortage exists in their specialty, in the
underserved area or for the underserved population. The shortage is determined by
creating a ratio of physicians to the population using a listing of physicians in that
specialty who provide service in the underserved area or for the underserved population
and the population of the underserved area or the number of individuals who comprise
the underserved population using the most recent data available. If the ratio of physician
to population is greater than 1:10,000, a greater shortage of that specialty exists in the
underserved area or underserved population. Documentation may include, but not be
limited to, the following:
A) A listing of specialists who provide service in the underserved area or for the
underserved population.
B) If there are no specialists who provide service in the underserved area or for the
underserved population, the applicant shall provide a summary listing the number
of patients in the underserved area who migrated out of the underserved area to
seek service. This summary shall be for the most recent 12-month period and
shall include the travel time and distance these patients traveled to obtain
service.
16. For specialists, documentation comparing wait times for an appointment with a physician
of the same specialty in the underserved area or for the underserved population.
Documentation may include, but not be limited to, the following:
A) A listing of specialists who provide service in the underserved area or for the
underserved population, including the average wait time for an appointment.
B) If there are no specialists who provide service in the underserved area or for the
underserved population, the applicant shall provide a summary listing the number
of patients who migrated out of the underserved area to seek service. The
summary shall be for the most recent 12-month period and shall include the
average wait time for an appointment.
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September 2022 Version Page 7
17. A completed and notarized Certification Statement A regarding the contractual
requirements in Section 214(k)(1)(B) and (C) of the Act.
18. A completed and notarized Certification Statement B describing the applicant's obligation
to his/her country of nationality or country of last legal residence. If the applicant has a
contractual obligation to return to his/her country of nationality or country of last legal
residence, the applicant shall obtain a letter from that country stating no objection to the
applicant remaining in the U.S.
19) A completed and notarized Certification Statement C attesting that the applicant's
medical license has never been suspended or revoked and that he/she is not subject to
any criminal investigation or proceedings by any medical licensing authority.
20) A completed and notarized Certification Statement D regarding the accuracy of the
application materials.
21) A completed and notarized Certification Statement E regarding medical specialty status.
22) Documentation that the medical facility is located in a shortage area (as applicable):
https://data.hrsa.gov/tools/shortage-area.
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 8
PHYSICIAN INFORMATION
Name: ______________________________________________________________________
Last First
U.S. Department of State Number (DOS): _________________________________________
Gender: ________________________________________________________________
Country of Birth: __________________________________________________________
Country of Origin: __________________________________________________________
Country of Residence: ____________________________________________________
I-94 Number: ________________________________________________________________
Medical Specialty: __________________________________________________________
Address: ________________________________________________________________
City, State, ZIP: __________________________________________________________
Email: work: ____________________ home: _____________________________
Phone: ______________________________________________________________________
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 9
CONTACT INFORMATION
APPLICANT CONTACT
Person who is to receive all correspondence or inquiries regarding the application:
Name: ______________________________________________________________________
Title: ______________________________________________________________________
Company Name: __________________________________________________________
Address: ________________________________________________________________
City, State, ZIP: __________________________________________________________
Telephone: ________________________________________________________________
Fax: ______________________________________________________________________
Email: ________________________________________________________________
WAIVER CONTACT
Person who is to receive all correspondence or inquiries subsequent to the issuance of a
waiver:
Name: ______________________________________________________________________
Title: ______________________________________________________________________
Company Name: __________________________________________________________
Address: ________________________________________________________________
City, State, ZIP: __________________________________________________________
Telephone: ________________________________________________________________
Fax: ______________________________________________________________________
Email: ________________________________________________________________
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 10
EMPLOYMENT INFORMATION
EMPLOYER
Include information regarding the physician's employer:
Name of employer: __________________________________________________________
Address: ________________________________________________________________
City, State, ZIP: __________________________________________________________
Telephone: ________________________________________________________________
Fax: ______________________________________________________________________
Contact person of employer: ____________________________________________________
Email of contact person: ____________________________________________________
Employer is (check one):
_____ Nonprofit Corporation _____ Partnership _____ Other
_____ For-profit Corporation _____ Governmental Entity
_____ Limited Liability Company _____ Sole Proprietorship
MEDICAL FACILITY
Include information regarding the medical facility where the physician will work (if the physician
will work at multiple facilities include this information for each facility):
Name of medical facility: ____________________________________________________
Address: ________________________________________________________________
City, State, ZIP: __________________________________________________________
HPSA ID Number (if applicable): _______________________________________________
Telephone: ________________________________________________________________
Fax: ______________________________________________________________________
Contact person at medical facility: _______________________________________________
Email of contact person: ____________________________________________________
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 11
Submission of Application
The application shall be submitted to IDPH to this address:
J-1 Visa Waiver Program
Illinois Department of Public Health
Center for Rural Health
535 West Jefferson Street, Ground Floor
Springfield, Illinois 62761-0001
Processing of Applications
Upon receipt, IDPH staff will verify completeness of the application. Completeness is based on
whether all applicable requirements have been addressed and whether all required materials
and documentation have been submitted.
If complete, the applicant will be considered for a waiver.
If the application is incomplete, IDPH will notify the applicant in writing. The applicant will have
30 calendar days (from the date of IDPH's notification) to address the issue(s) identified and
to submit requested information or materials. If the applicant does not respond to the notification
within the prescribed time frame or if the supplemental materials or information fail to address
the issue(s) identified by IDPH, the application will be null and void.
The applicant will be notified in writing of IDPH's decision on the waiver. If IDPH recommends a
waiver, the application package will be forwarded to the USDOS.
Number of Waiver Applications to be Processed
The Act allows IDPH to submit 30 waiver requests per federal fiscal year. When IDPH has
processed 30 waiver requests, subsequent applications will not be considered.
Selection Process
IDPH will not begin the selection process until all issues with incomplete applications are
resolved.
The following selection criteria will be used:
1. In the first and second calendar quarters of the federal fiscal year, a maximum of two
waiver applications may be approved for physicians working at the same medical facility.
In subsequent calendar quarters, applications from physicians proposing to work at
medical facilities that have already employed two physicians with waivers will be
considered; however, selection priority will be given to applications from physicians
proposing to work at medical facilities that have not previously employed physicians with
waivers.
2. For primary care physicians and psychiatrists:
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 12
A) Applicants will be ranked based on the Primary Care HPSA score or the Mental
Health HPSA score (as applicable) of their respective medical facility. If an
applicant proposes to work at more than one medical facility, the Primary Care
HPSA score or the Mental Health HPSA score of the medical facility where the
applicant will predominately work will be used to rank the applicant.
B) If two or more medical facilities have the same HPSA score, preference will be
given to the medical facility with the greatest unmet need for primary care
physicians and psychiatrists (as applicable). Unmet need is defined as the
number of primary care physician or psychiatrist full-time equivalents needed to
cause the HPSA to no longer meet the threshold ratio for HPSA designation.
C) An application will not be considered if the inclusion of the applicant will increase
the number of primary care physicians or psychiatrists beyond the number
needed to eliminate the HPSA designation for the geographic area, facility, or
population group.
3) For specialists:
A) Applicants will be ranked based on the Primary Care HPSA score of their
respective medical facility. If an applicant proposes to work at more than one
medical facility, the Primary Care HPSA score of the medical facility where the
applicant will predominately work will be used.
B) If two or more medical facilities have the same HPSA score, preference will be
given to the medical facility having the greatest unmet need for specialty medical
care.
C) Specialists who applied through the Flex Waiver option shall be ranked based on
the greater number of patients that will be seen at the medical facility.
4. The following selection allocations will be used in processing waiver applications:
A) In the first calendar quarter of the federal fiscal year, four waivers will be
reserved for psychiatrists who will work in rural medical facilities, six waivers will
be reserved for primary care physicians who will work in rural medical facilities,
seven waivers will be reserved for primary care physicians who will work in urban
medical facilities, and 13 waivers will be available to specialists. Of the 13
waivers allocated to specialists, IDPH may approve up to 10 waivers under the
Flex Waiver option.
B) In the second and third quarters of the federal fiscal year, remaining waivers may
be used for primary care, psychiatry, and specialists in both rural and urban
areas.
Semi-annual Verification of Physician’s Medical Practice
Each six months subsequent to the date of the granting of the waiver by USCIS, IDPH shall
request written verification of the full-time practice of the physician in the shortage area
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 13
indicated in the employment contract originally submitted with the waiver application. If at any
time the physician fails to practice on a full-time basis in the approved shortage area, the USCIS
will be notified of the recipient’s breach of obligation.
NOTE: All questions regarding the J-1 Visa Waiver Program should be directed to IDPH’s
Center for Rural Health at 217-782-1624, TTY (hearing impaired use only) at 800-547-0466 or
to dph.j1waiver@illinois.gov
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 14
CERTIFICATION STATEMENT A
APPLICANT PHYSICIAN ASSURANCES FOR J-1 VISA WAIVER APPLICATIONS
This is to certify that I, __________________________________________________________
Printed / Typed Last Name First Name Middle
agree to comply with the contractual requirements set forth in Section 214(k)(1)(B) and (C) [8
U.S.C. 1184 (k)(1)], stated below:
The alien demonstrates a bona fide offer of “full-time” (40 hours) employment at a health care
facility and agrees to begin employment at such facility within 90 days of receiving such waiver
and agrees to continue to work in accordance with paragraph (2) at the health care facility in
which the alien is employed for a total of not less than three years (unless the Attorney General
determines that extenuating circumstances such as the closure of the facility or hardship to the
alien would justify a lesser period of time)
The alien agrees to practice medicine in accordance with paragraph (2) for a total of not less than
three years only in a geographic area or areas, which are designated by the Secretary of Health
and Human Services as having a shortage of health care professionals.
I hereby declare and certify, under penalty of the provisions of 18 USC.1001, that: 1) I have
sought or obtained the cooperation of the Illinois Department of Public Health which is
submitting an IGA request on behalf of me under the Conrad 30 program to obtain a waiver of
the two-year home residency requirement; and 2) I do not now have pending nor will I submit
during the pendency of this request, another request to any U.S. government department or
agency or any equivalent, to act on my behalf in any matter relating to a waiver of my two-year
home residence requirement.
________________________________________ _______________________
Signature of Physician Seeking Waiver Date
Attested by
State of __________________________________
County of __________________________________
Signed or attested before me on __________________________________________ (date) by
____________________________________________________________(name of person/s).
___________________________________
Signature of Notary Public
Notary Seal
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 15
CERTIFICATION STATEMENT B
CONTRACTUAL OBLIGATION TO HOME COUNTRY
This is to certify that I, __________________________________________________________
Print/Type Last Name First Name Middle
Check one: ______ have ______ do not have
a contractual obligation to return to my home country or country of last residence.
________________________________________ _________________
Signature of Physician Seeking Waiver Date
Attested by
State of ___________________________
County of ___________________________
Signed or attested before me on __________________________________________ (date) by
____________________________________________________________ (name of person/s).
_____________________________
Signature of Notary Public
Notary Seal
NOTE: If you indicated you have a contractual obligation to a country, you must obtain a letter from that
country stating no objection to you remaining in the U.S. You should request this letter from your
embassy in Washington, D.C., or from your home country. The letter should be sent to the director of the
United States Information Agency through the United States Embassy in your home country. It also can
be sent through the foreign country’s head of mission or duly appointed designee in the United States to
the director of the United States Information Agency in the form of a diplomatic note. This note shall
include applicant's full name, date and place of birth, present address and the language “…pursuant to
Public Law 103-416.” You should also request a copy of the no objection letter be sent to you for your
files.
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 16
CERTIFICATION STATEMENT C
MEDICAL LICENSE STATUS
This is to certify that I, __________________________________________________________
Print/Type Last Name First Name Middle
am not subject to any criminal investigation or proceedings by any medical licensing authority,
nor has my medical license ever been suspended or revoked.
____________________________________________ _________________
Signature of Physician Seeking Waiver Date
Attested by
State of ____________________________
County of ____________________________
Signed or attested before me on ___________________________________________(date) by
____________________________________________________________ (name of person/s).
___________________________________
Signature of Notary Public
Notary Seal
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 17
CERTIFICATION STATEMENT D
ACCURACY OF APPLICATION INFORMATION
This is to certify that the information presented in this application for assistance from the Illinois
Department of Public Health to request a waiver of the home residency requirement for the
applicant indicated below is accurate and correct to the best of my knowledge.
Health Care Facility/Agency Applicant
___________________________________ ___________________________________
Printed or Typed Name Printed or Typed Name
___________________________________ ___________________________________
Signature Signature
___________________________________ ___________________________________
Title or Position with Facility/Agency Date
___________________________________
Facility/Agency Name
___________________________________
Date
Attested by
State of ____________________________
County of ____________________________
Signed or attested before me on __________________________________________ (date) by
____________________________________________________________ (name of person/s).
___________________________________
Signature of Notary Public
Notary Seal
Illinois Department of Public Health, J-1 Visa Waiver Application
September 2022 Version Page 18
CERTIFICATION STATEMENT E
MEDICAL CARE SPECIALTY
This is to certify that I, __________________________________________________________
Print/Type Last Name First Name Middle
check one: _______ am board eligible _____ am board certified
In the specialty/specialties listed below.
Check applicable specialty:
____ Family Practice ____ General Internal Medicine
____ General Pediatrics ____ Obstetrics/Gynecology
____ Combined Medicine/Pediatrics ____ Psychiatry
____ Other (Specify)_____________________
___________________________________ _______________________
Signature of Physician Seeking Waiver Date
Attested by
State of ______________________________
County of ______________________________
Signed or attested before me on __________________________________________ (date) by
____________________________________________________________ (name of person/s).
___________________________________
Signature of Notary Public
Notary Seal
