HPSA Designation Application Form
Please fill out the following details to apply for HPSA designation.
Applicant Full Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Location Address
*
Practice Location City
*
Practice Location State/Province
*
Type of Health Practice
*
Please Select
Primary Care
Dental
Behavioral Health
Other
Describe the Practice Setting
*
Number of Patients Served Annually
*
Does the practice serve a designated shortage area?
*
Yes
No
Justification for HPSA Application
*
Contact Person Name (if different)
Submit Application
Should be Empty: