Oregon Office of Rural Health

Rural Medical Practitioners Insurance Subsidy Affidavit for NPs

Your Information

Full Name
Are you employed by a licensed physician?
Are you certified to provide Obstetric Care?

CURRENT PRIMARY Practice Physical Address

Primary Practice Address

Number of hours spent weekly in this location (please do not include time on call or travel time)
Do you have a Secondary Practice?

CURRENT SECONDARY Practice Physical Address

Secondary Practice Address

Number of hours spent weekly in this location (please do not include time on call or travel time)
Do you have Additional Practice Sites?
Please list additional practices
I attest that I am willing to serve Medicare and Medicaid patients in at least the same proportion to the total number of my patients as the Medicare and Medicaid populations represent to the total number of people in the rural areas of the county in which I practice.

I hereby certify that all information supplied in this affidavit is accurate to the best of my knowledge. I understand that if my practice location or insurance carrier changes, I must notify the Office of Rural Health within 10 days of the change so that a determination can be made regarding my continued eligibility for this benefit.