Arizona Loan Repayment Program

Loan Repayment Contracts – Repayment

Payments are generated quarterly upon receipt of the Service Verification FormPDF and Encounter Report FormPDF submitted immediately by the provider after completion of each 90-day of service. Prior to making loan repayment, ADHS will verify that a completed Service Verification form is submitted. A complete Service Verification form must include the following:

  • Name of the primary care provider
  • Name and address of the approved service site
  • Beginning and end dates of the 90-day period. NOTE: For the first payment, the begin date of the 90-day service must not be prior to the effective date of the State contract. Otherwise, those services are not creditable.
  • A statement that the provider has provided full-time, continuous service at the service site for the 90-day period
  • The notarized signature of the primary care provider certifying that the aforementioned continuous service statement is true
  • The notarized signature of the individual in the senior leadership position at the service site (i.e. Manager or Executive Director) that the aforementioned continuous service statement is true

Following receipt of a complete Service Verification Form, ADHS will make payments directly to the recipient's qualifying lending institution(s). A delay in the provider's submission of the Service Verification and Encounter Report Forms will result in the delay in lender payment.

Since there will be a three month period of time before the first payment is made to the lender(s), the recipient must coordinate with each lender to make necessary adjustments to the payment schedule for each loan so that quarterly payments will not result in default.

NOTE: The recipient remains responsible for timely repayment of the loan or loans.