Mississippi State Loan Repayment Program (SLRP): Sponsoring Entity (Practice Site)

The program recruits and retains healthcare professionals to serve at eligible practice sites located in health professional shortage areas (HPSAs).

HPSAs can be geographic areas, populations, or facilities. These areas have a shortage of primary, dental, or mental health care providers.

Program participants (MDs and DOs ONLY) must practice at least two years at an approved public or private healthcare organization and can receive up to $150,000.00 toward educational loan repayment.

Project Details

• Reference ID: 2026-RFA-173
• Department: Office of State Health Planning and Research
• Department Head: Jennifer Gholson (-)

Important Dates

• Questions Due: 2029-05-28T05:00:00.000Z

Evaluation Criteria

• HRSA Designation (10 pts) —

  Confirm that the practice site is located within a federally designated Health Professional Shortage Area (HPSA) or serves a population within a HPSA. Documentation should include the HPSA score and designation type (geographic, population, or facility). This ensures the site meets eligibility criteria for serving underserved communities.

• Practice Site Policy on Non-Discrimination (10 pts) —

  Review the site’s written non-discrimination policy to ensure it complies with federal regulations. The policy must clearly state that services are provided regardless of race, color, national origin, sex, age, disability, religion, or ability to pay. The document should be current, formally adopted, and applicable to all patients.

• Practice Site Policy for Sliding Fee Scale (10 pts) —

  Verify that the practice site has an established sliding fee discount program for patients with limited income. The policy must outline eligibility criteria, income thresholds (typically based on federal poverty guidelines), and the process for determining discounted fees. This ensures access to care for uninsured and underinsured populations.

• Performance Outcomes (10 pts) —
  1. 1. 1. Subgrantees Seeking Renewal - Applicants will receive higher scores if their agency met the performance requirements outlined in the previous subgrant agreement. If any of those applicants did not meet the required performance metrics during the previous program year, applicants will receive higher scores if a clear and reasonable justification for not meeting the performance requirements is provided.
        2. New Applicants - Applicants that have not previously received this funding will receive higher scores if a strong description of experience and quality outcomes relevant to this project is provided.
• Quality of Application (10 pts) —

  Applications will receive higher scores if the information presented is accurate, complete, well-presented, and free of spelling, grammatical, and mathematical mistakes. Additionally, all acronyms must be spelled out at their first mention, indicating their abbreviation in parenthesis.

• Photo of Sign for Non-Discrimination and Sliding Fee (10 pts) —

  Confirm submission of photographic evidence showing that both the non-discrimination policy and sliding fee scale information are publicly displayed at the practice site. The signage must be clearly visible and accessible to patients (e.g., in waiting areas or reception). This demonstrates transparency and compliance with program requirements.

• Recruitment and Retention Plan (10 pts) —

  Evaluate the site’s recruitment and retention plan for healthcare providers. The plan should describe strategies to attract qualified clinicians, support workforce stability, and retain providers long-term, particularly in underserved areas. Consideration should be given to incentives, professional development opportunities, and community integration efforts.

• Completed W-9 (10 pts) —

  Ensure that a current and fully completed IRS Form W-9 is submitted for the practice site. The form must include the correct legal business name, taxpayer identification number (TIN), and signature. This document is required for payment processing and financial compliance.

Submission Requirements

• Health Care Practice Site Information
• Health Care Practice Site Name (required) —

  Please provide the full legal name of the Applicant Organization that should be listed on an agreement or contract. Be sure to include any other "doing business as" names, or any previous names the organization used.

  NOTE: Name must match the UEI Number

• Health Care Practice Site UEI Number (required) —

  Please enter the full UEI Number of the Applicant Organization here.

• UEI Number Upload (required) —

  Please upload a copy or printout of your registration from SAM.gov.

• Health Care Practice Site Address (required) —

  What is the full physical/mailing address of the Application Organization?

  Please be sure to include the full street name and address (including floor or room number if applicable), City, State, and Zip Code.

• Health Care Practice Site Contact Information - Name (required) —

  Please designate a primary contact person for this practice site. This individual will be responsible for responding to quarterly verification requests from the State to confirm provider contract compliance.

  The contact person should be knowledgeable about provider schedules, employment status, and service obligations, and must be available to provide timely and accurate information when requested.

  The designated contact person may include, but is not limited to:

  • Practice Manager or Clinic Administrator
  • Medical Director or Clinical Supervisor
  • Office Manager or Front Office Supervisor
  • Human Resources Representative
  • Credentialing or Compliance Coordinator
• Health Care Practice Site Contact Information - Title (required) —

  Please provide the full title of the Applicant's Point of Contact for this Application.

• Health Care Practice Site Contact Information - Telephone Number (required) —

  Please provide the full telephone number (including area code) of the Applicant's Point of Contact for this Application.

• Health Care Practice Site Contact Information - Email Address (required) —

  Please provide the full email address of the Applicant's Point of Contact for this Application.

• Health Care Practice Site Authorized Signer Name, Title (required) —

  Please provide the name and title of the individual authorized to sign official documents on behalf of the health care practice site. This person has legal authority to bind the organization in contractual agreements, certifications, and other required program documentation.

  The authorized signer is typically a practice owner, chief executive officer, medical director, or other designated executive-level representative. This individual must ensure that all submitted information is accurate and that the practice site agrees to comply with program requirements.

• Health Care Practice Site Authorized Signer Telephone Number (required)
• Health Care Practice Site Authorized Signer Email Address (required)
• Provide practice site policy on non-discrimination of patients based on race, color, sex, national origin, disability, religion, age, or sexual orientation. (required)
• Provide practice site policy for the sliding fee scale discount or financial assistance and the patient application for financial assistance, if applicable. (required)
• Provide photograph of posted signage of the non-discrimination policy and sliding fee scale/financial assistance policy. (required)
• Provide recruitment and retention plan to retain the health care professional upon completion of the service obligation. (required)
• Is the practice site a Federally Qualified Health Center (FQHC) or Look-a-like (FQHC-LAL) (required) —

  Federally Qualified Health Centers (FQHCs) are community-based and patient- directed organizations that provide affordable, accessible, high-quality primary health care services to individuals and families, including people experiencing homelessness, agricultural workers, residents of public housing, and veterans.

  1. • Community Health Centers
     • Migrant Health Centers
     • Homeless Programs
     • Public Housing Programs
• Is the practice site a Rural Health Center (RHC)? (required) —

  Centers for Medicare & Medicaid Services Certified Rural Health Clinics

• Is the practice site one of the other health facilities? (required) —
  1. • Community Outpatient Facilities
     • Community Mental Health Facilities
     • State and County Health Department Clinics
     • Immigration and Customs Enforcement Health Service Corps
     • Free Clinics
     • Mobile Units
     • School-based programs
     • Critical Access Hospitals affiliated with a qualified outpatient clinic
     • State Mental Health Facilities
     • Rural Emergency Hospitals affiliated with a qualified outpatient clinic
• Is the practice site an Indian Health Service Facility (required) —
  1. • Federal Indian Health Service (IHS) Clinical Practice Sites
     • Tribal/638 Health Clinics
     • Urban Indian Health Program
     • IHS and tribal hospitals
• Is the practice site a correctional or detention facility? (required) —
  1. • Federal Prisons
     • State Prisons
• Is the practice site a public or non-profit private entity? (required) —

  Non-profit private entity” means an entity that may not lawfully hold or use any part of its net earnings to the benefit of any private shareholders or individual and which does not hold or use its net earnings for that purpose.

  • • • Non-profit organizations that operate for-profit health care facilities must accept reimbursement from Medicare, Medicaid, and the Children’s Health Insurance Program.
• Does the practice site accept patients regardless of insurance or ability to pay? (required)
• Does the practice site accept new patients? (required)
• Does the practice site accept Medicaid/ Children's Health Insurance Program? (required)
• If yes to question 1.24, provide Medicaid number:
• Does the practice site accept new Medicaid/ MSCAN patients? (required)
• Does the practice site accept Medicare? (required)
• If yes to question 1.27, provide Medicare number:
• Does the practice site accept new Medicare patients? (required)
• Does the practice site offer a sliding fee scale or income-based financial assistance to patients? (required)
• Does the practice site have a recruitment and retention plan in place? (required)
• On average, how many days does it take to schedule a routine, non-urgent appointment? (required) —

  Please indicate the average number of days it takes for a patient to schedule a routine, non-urgent appointment at the practice site. This refers to the typical wait time from the date a patient requests an appointment to the earliest available scheduled visit for non-urgent care.

  Responses should reflect standard operating conditions and routine scheduling capacity, excluding emergency or urgent care visits. If scheduling times vary, provide an estimated average based on typical patient access patterns.

• On average, how many days does it take to schedule a new patient routine, non-urgent appointment? (required) —

  Please indicate the average number of days it takes to schedule a routine, non-urgent appointment for a new patient at the practice site. This refers to the typical time between a new patient’s initial request for care and the earliest available scheduled appointment.

  Do not include urgent or emergency visits. If scheduling times vary, provide an estimated average based on standard appointment availability and routine access patterns for new patients.

• What percent of patients utilize the sliding fee/financial assistance? (required) —

  Please indicate the approximate percentage of patients at the practice site who utilize the sliding fee scale or receive financial assistance. This should reflect the proportion of total patients seen who are enrolled in or approved for discounted or financial assistance programs based on eligibility criteria.

  Provide an estimated average based on typical patient volume and billing practices. If no patients utilize the sliding fee or financial assistance program, enter 0%.

• Practice Site Data (Previous Calendar Year) (required) —

  Please complete the practice site data tables using information from the previous calendar year. Include only individuals who received direct patient care services at the practice site.

  Exclude individuals with limited contact with the clinic. Limited contact includes, but is not limited to:

  • Individuals who only received services through large-scale or one-time events (e.g., immunization drives, screening programs, health fairs, or community-wide service initiatives)
  • Individuals who only participated in outreach activities or group education sessions where no direct patient care services were provided
  • Individuals whose only interaction with the practice site was for ancillary or minimal services, such as laboratory tests, x-rays, immunizations or injections, tuberculosis (TB) testing or readings, or prescription filling/refilling

  Ensure that all data reported reflects routine, ongoing patient care and accurately represents the patient population served by the practice site.

• Eligible Entity (required) —

  Party submitting this application certifies that Applicant Organization is an eligible entity as defined by this RFA. Practice Site eligibility requirements can be found in the SLRP Overview & Guidelines document. 

• Debarment or Suspension Confirmation (required) —

  Party submitting this application certifies that Applicant Organization is not presently debarred or suspended.

• W9 (required) —

  Upload a copy of your current W9 here.

• Conflicts of Interest
• Other Current MSDH Contracts (required) —

  List all other current agreements/contracts with MSDH, including the dollar amount associated with the agreement/contract and the beginning and ending dates. If no other funds are received, please mark N/A.

  Please provide each entry in the following format:

  MSDH Program or Agreement/Contract Name #1

  • Dollar Amount
  • Contract Beginning Date
  • Contract Ending Date
• Organization Governing Body (required) —

  Please list the name of each member of your organization’s Board of Directors or other governing body (i.e., trustee, alderman, partner, owner).

• Governing Body or Project Staff Affiliations (required) —

  Are any members of the governing body or project staff also MSDH employees, MSDH Board Members, or spouses, parents, or children of MSDH employees?

• Governing Body or Staff Affiliations - Explanation (required) —

  You have indicated that one or more members of your governing body or project staff are also MSDH employees, MSDH Board Members, or spouses, parents, or children of MSDH employees.

  Please provide the following for all such individuals:

  • Name of Individual
  • Indicate if individual is an MSDH Employee, MSDH Board Member, or relative type of MSDH employee.
  • Applicable position held with MSDH
• Income From Business (required) —

  Does the MSDH Board Member, Employee, or Relative receive more than $2,500.00 per year in income from the business?

• Ownership Status - Percentage (required) —

  Does the MSDH Board Member, Employee, or Relative own ten (10%) percent or more of the fair market value in the business, either directly or indirectly through another business?

• Ownership Status - Amount —

  Does the MSDH Board Member, Employee, or Relative have ownership interest in the business, in which the fair market value exceeds $5,000.00?

• Position Within Business (required) —

  Is the MSDH Board Member, Employee, or Relative a director, officer, or employee of the business?

• Conflict of Interest Certification (required) —

  I hereby certify that the information set forth above is true and complete to the best of my knowledge and that no MSDH employee, spouse, parent, or child of an MSDH employee, serves as a member of the governing body, project staff, or has an ownership or pecuniary interest in the agreement/contract or organization. I agree to notify MSDH within thirty (30) days if any of these conditions change during the agreement/contract.

• Health Professional Shortage Area (HPSA) —

  Please indicate the type of Health Professional Shortage Area (HPSA) designation for the practice site. HPSA types identify the specific category of shortage and may include Primary Care, Dental Health, or Mental Health designations.

  Select the HPSA type that best corresponds to the services provided at the practice site, based on the official federal designation. This information is used to verify site eligibility for workforce incentive and loan repayment programs.

• HPSA Type (required)
• Provide HPSA Score (required) —

  Please provide the current Health Professional Shortage Area (HPSA) score for the practice site. The HPSA score is a federally assigned value used to measure the severity of provider shortage in a designated area or population and is used to determine program eligibility and priority.

  To locate the HPSA score, visit the HRSA Data Warehouse at Health Workforce Shortage Areas  and search by practice site address or name. Ensure the score entered reflects the most current federal designation at the time of application submission.

• List practice site geographic boundaries or population centers served by the practice site. (required)
• Other
• Debarment, Suspension, and Eligibility (required) —

  The applicant certifies that they or any of its principals _____ presently debarred, suspended, proposed for debarment, or declared ineligible for award of federal or state contracts.

  Select the answer which best fills in the blank for the applicant.

• Charges From A Government Agency (required) —

  The applicant certifies that they or any of its principals _____ presently indicted for, or otherwise criminally or civilly charged by a government entity.

  Select the answer which best fills in the blank for the applicant.

• Conviction or Acknowledgment of Fault (required) —

  The applicant certifies that they or any of its principals _____ within the last five (5) years, been the subject of a federal or state criminal proceeding resulting in a conviction or other acknowledgment of fault, been the subject of a federal or state civil or administrative proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000 or other acknowledgment of fault;  convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) contract or subcontract; violation of Federal or State antitrust statues relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements or receiving stolen property.

  Select the answer which best fills in the blank for the applicant.

• Contract Termination By Default (required) —

  The applicant certifies that they or any of its principals _____ within the last five (5) years preceding this offer, had one or more contracts terminated for default by any federal agency.

  Select the answer which best fills in the blank for the applicant.

• Felony Criminal Violations (required) —

  The applicant certifies that they or any of its principals _____ within the last five (5) years, been convicted of a felony criminal violation under federal or state law.

  Select the answer which best fills in the blank for the applicant.

• Please acknowledge that any work performed prior to execution is done at the vendor’s own risk and may not be eligible for payment. MSDH reserves the right, in its sole discretion, to determine on a case-by-case basis whether payment is allowable based on the particular circumstances. (required)
• Conditions and Requirements as an approved Practice Site (Sponsoring Entity) (required) —

  SLRP Sponsoring Entity Requirements – Description

  As a State Loan Repayment Program (SLRP) Practice Site/Sponsoring Entity, you are required to comply with the following conditions and responsibilities:

  • MAGIC Registration: All entities receiving payments from State government agencies must be registered in Mississippi’s Accountability System for Government Information and Collaboration (MAGIC), unless exempt. For assistance, contact the Department of Finance and Administration at mash@dfa.ms.gov or visit http://www.dfa.ms.gov/dfa-offices/mmrs.
  • Invoice Verification: Review and verify all invoices submitted by the Mississippi State Department of Health (MSDH).
  • Disbursement of Funds: SLRP payments will be issued directly to the sponsoring entity (facility). The facility is responsible for disbursing the full award amount to the approved health care provider. Funds must be deposited as a one-time lump sum into the participant’s account within thirty (30) days of receipt from MSDH. Proof of payment must be submitted to MSDH within forty-five (45) days.
  • Verification Requirements: Submit loan verification and employment verification forms to MSDH upon request.
  • Notification of Changes:
    • Notify MSDH immediately if the provider is relocated.
    • Notify MSDH immediately of any changes to the practice site’s administrative representative.
    • Notify MSDH immediately if the employment agreement with the participant is terminated.
  • Program Compliance: Comply with all applicable provisions of Medicare (Title XVIII) and Medicaid (Title XIX) of the Social Security Act.
  • Use of Funds: SLRP funds must not be used as a salary offset.
  • Absence Reporting: Report to MSDH within ten (10) days if the participant is absent from the approved practice site(s) for more than thirty-five (35) full-time working days during the agreement year.
  • Additional Compensation: Any additional benefits, services, or compensation provided by the Sponsoring Entity are outside the scope of the SLRP agreement and do not create any obligation or liability for MSDH.

  Failure to comply with these requirements may result in program non-compliance and potential penalties.

• Health Care Practice Site Attestation (required) —

  I have read and understand the Overview and Guidelines Document, which describes the requirements of the Mississippi State Loan Repayment Program (SLRP) that the practice site meets the qualifications for participation in the program. I understand that the information I have provided is subject to verification, and providing willfully false information will result in disqualification from the SLRP.

• Competition/Joint Efforts Verbiage (required) —

  Should the language for Competition/Joint Efforts be used in this RFA?

• Statement of Need (required) —

  Is there a Statement of Need required with submittals for this RFA?

• Estimated Dollar Amount (required) —

  What is the estimated dollar amount budgeted for this request?

• Funding Information —

  Be sure that the following three financial info pieces add up to 100% or this will not be approved.

• Internal Order (required) —

  Please specify the internal order information. Be sure to include the % of each internal order. If there are multiple internal orders, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  30000035771  100%

• Functional Area (required) —

  Please specify the functional area information. Be sure to include the % of each functional area. If there are multiple functional areas, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  13010101000000DV  100%

• Cost Center (required) —

  Please specify the cost center information. Be sure to include the % of each cost center. If there are multiple cost centers, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  1301010707  100%