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This form is used by health professionals participating in the Washington State Health Professional Loan Repayment Program to verify their service hours and compliance with program requirements.
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How to fill out Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form
01
Obtain the Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form from the program's official website or your program coordinator.
02
Fill out your personal information in the designated sections, including your name, contact information, and service location.
03
Document the specific dates of service within the quarter for which you are reporting.
04
Indicate the number of hours worked each week and the total for the quarter.
05
Write a brief description of the services provided during this period.
06
Obtain the necessary signatures from your supervisor or facility director to validate your service.
07
Review all information for accuracy and completeness.
08
Submit the completed form to the requested address or email provided, ensuring it is sent by the deadline.
Who needs Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
01
Healthcare professionals who are participants in the Washington State Health Professional Loan Repayment Program seeking to verify and document their service hours.
02
Providers who are fulfilling their service obligations as outlined in their loan repayment agreement.
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What is Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
The Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form is a document that participants in the loan repayment program must complete and submit every quarter to verify their service hours and compliance with the program requirements.
Who is required to file Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
Participants of the Washington State Health Professional Loan Repayment Program who are receiving loan repayment assistance in exchange for their service in designated healthcare shortage areas are required to file this form.
How to fill out Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
To fill out the form, participants must provide their personal information, validate their quarterly service hours, and include signatures from both the participant and their supervisor confirming the accuracy of the reported information.
What is the purpose of Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
The purpose of the form is to ensure that participants are fulfilling their service commitments as agreed upon in their loan repayment contracts in exchange for financial assistance.
What information must be reported on Washington State Health Professional Loan Repayment Program Quarterly Service Verification Form?
The information that must be reported includes the participant's name, contact details, service dates, total hours worked, the type of services rendered, and signatures from the participant and their supervisor.
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