Part I
Definitions and General Information

12VAC5-508-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Accredited "Approved residency" means a graduate medical education program in family practice medicine, general internal medicine, pediatric medicine, or obstetrics and gynecology, or psychiatry accredited by approved by the board. In determining whether a course of study is acceptable, the board may consider the reputation of the program and whether it is approved or accredited by (i) a regional or national educational or professional association, including such organizations as the Liaison Committee on Accreditation Council for Graduate Medical Education, Liaison Committee on Medical Education, Council on Postgraduate Training of the American Osteopathic Association, Council on Osteopathic College Accreditation, College of Family Physicians of Canada, Committee for the Accreditation of Canadian Medical Schools, Education Commission on Foreign Medical Graduates, or Royal College of Physicians and Surgeons of Canada, or their appropriate subsidiary agencies; (ii) any appropriate agency of the United States government; or (iii) any other organization approved by the board.

"Board" or "Board of Health" means the State Board of Health.

"Commercial loans" means loans made by banks, credit unions, savings and loan associations, insurance companies, schools, and either financial or credit institutions that are subject to examination and supervision in their capacity as lenders by an agency of the United States or of the state in which the lender has its principal place of business.

"Commissioner" means the State Health Commissioner.

"Department" means Virginia Department of Health.

"Full-time" means at least 40 32 hours per week for 45 weeks per year.

"Geriatrics fellowship" means a geriatrics subspecialty training program following residency approved by the board. In determining whether a course of study is acceptable, the board may consider the reputation of the program and whether it is approved or accredited by (i) a regional or national educational or professional association, including such organizations as the Accreditation Council for Graduate Medical Education, Liaison Committee on Medical Education, Council on Postgraduate Training of the American Osteopathic Association, Council on Osteopathic College Accreditation, College of Family Physicians of Canada, Committee for the Accreditation of Canadian Medical Schools, Education Commission on Foreign Medical Graduates, or Royal College of Physicians and Surgeons of Canada, or their appropriate subsidiary agencies; (ii) any appropriate agency of the United States government; or (iii) any other organization approved by the board.

"Health Professional Shortage Area" professional shortage area" or "HPSA" means a geographic an area in Virginia designated by the Bureau of Primary Health Care, Health Resources and Services Administration U.S. Secretary of Health and Human Services as medically underserved having a shortage of health professionals in accordance with the procedures of the Public Health Service Act (42 USC § 254e) and implementing regulations (42 CFR Part 5.2) 5).

"Participant" or "loan repayment participant" means an eligible primary care physician or an eligible psychiatrist a physician currently employed in a geriatrics fellowship who enters into a contract with the commissioner and participates in the loan repayment program.

"Penalty" means the amount of money equal to twice the amount of all monetary loan repayment payments paid to the loan repayment participant, less any service obligation completed.

"Practice" means the practice of medicine by a recipient participant in a geriatrics fellowship or in one of the designated primary care specialties in a specific geographic area determined to be fulfillment of fulfill the recipient's participant's loan repayment obligation.

"Primary care" means the specialties of family practice medicine, general internal medicine, pediatric medicine, and obstetrics and gynecology, and psychiatry.

"Reasonable educational expenses" means the costs of education, exclusive of tuition, that are considered to be required by the school's degree program or an eligible program of study, such as fees for room, board, transportation and commuting costs, books, supplies, educational equipment and materials, and clinical travel, which that was a part of the estimated student budget of the school in which the participant was enrolled.

"State or local institution" means any Virginia state agency or local government agency that may require services of a primary care practitioner. This includes, but is not limited to, the Department of Health, the Department of Behavioral Health and Developmental Services, the Department of Corrections, the Department of Juvenile Justice, and local community services boards.

"Virginia medically underserved area" or "VMUA" means a geographic an area in Virginia designated by the State Board of Health in accordance with the Rules and Regulations for the Identification of Medically Underserved Areas in Virginia (12VAC5-540) or and § 32.1-122.5 of the Code of Virginia, or designated as a federal health professional shortage area (HPSA) in Virginia by the Bureau of Primary Health Care, Health Resources and Services Administration in accordance with the procedures of the Public Health Service Act (42 USC § 254e) and implementing regulations (42 CFR Part 5.2).

12VAC5-508-20. General information and purpose of chapter. (Repealed.)

These regulations set forth the criteria for eligibility for the Virginia Physician Loan Repayment Program; the general terms and conditions applicable to the obligation of each loan repayment recipient to practice in a state or local institution or a medically underserved area of Virginia, as identified by the Board of Health by regulation or a federal HPSA in Virginia, designated by the Bureau of Primary Health Care, Health Resources and Services Administration; and penalties for a recipient's failure to fulfill the practice requirements of the Virginia Physician Loan Repayment Program.

The purpose of the Virginia Physician Loan Repayment Program is to improve the recruitment and retention of primary care practitioners in underserved areas of Virginia and in state and local institutions. A limited number of loan repayment participation contracts will be signed with participants in return for service in a designated Virginia Medically Underserved Area (VMUA) or HPSA, and targeted at practitioners located in non-profit community-based or hospital-based primary care centers. Private-for-profit entities will be eligible depending on the insurance status of the patient population. State and local institutions are eligible. Loan repayment benefits are to be used to repay outstanding qualifying medical educational loans and are based on the availability of funds.

12VAC5-508-30. Compliance with the Administrative Process Act. (Repealed.)

Chapter 40 (§ 2.2-4000 et seq.) of Title 2.2 of the Code of Virginia (the Administrative Process Act) governs the promulgation and administration of this chapter and applies to any appeal of a case decision made pursuant to or based upon this chapter.

Part II
Administration of the Virginia Physician Loan Repayment Program

12VAC5-508-40. Administration. (Repealed.)

The State Health Commissioner, as executive officer of the Board of Health, shall administer this program. Any requests for variance from these regulations shall be considered on an individual basis by the board in regular session.

12VAC5-508-50. Eligible applicants.

Eligible applicants for the Virginia Physician Loan Repayment Program must shall:

1. Be a citizen of the United States citizen, national, or a qualified alien pursuant to 8 USC § 1621;

2. Have graduated from an accredited medical school;

2. 3. Be an allopathic (M.D.) or osteopathic (D.O.) physician who is enrolled in the final year of an approved residency program in allopathic medicine, or osteopathic medicine, psychiatry, or already in practice;, and who will have completed post-graduate training in an accredited approved residency in specialties of family practice medicine, general internal medicine, general pediatrics, obstetrics/gynecology, osteopathic general practice or psychiatry or be employed or accepted in a geriatrics fellowship when the period of obligated service begins. Note that obstetrics/gynecology practitioners must provide prenatal care and obstetric service to be eligible for the Virginia Physician Loan Repayment Program. Practitioners who practice only gynecology are not eligible to participate in the loan repayment program;

3. 4. Have a valid unrestricted Virginia license to practice medicine, a copy of which shall be furnished to the Virginia Physician Loan Repayment Program;

4. 5. Have submitted a completed application to participate in the Virginia Physician Loan Repayment Program; and

5. Have signed and submitted a written contract agreeing to repay educational loans and to serve for the applicable period of obligated service in an area of defined need.

6. Have no other contractual service obligation unless completely satisfied before the physician loan repayment program contract has been signed;

7. Not have an active military obligation;

8. Be employed or have a contract for employment in an HPSA, a VMUA, an approved geriatrics fellowship, or a state or local institution within a month of the completion of the approved residency program or within a month of the application date, whichever is later;

9. Not have a history of failing to comply with, or inability to comply with, service or payment obligations;

10. Not have a history of noncompliance within any other state or federal scholarship or loan repayment program; and

11. Have an educational loan balance that can be verified.

12VAC5-508-60. Application requirement and restrictions.

The applicant must shall submit a completed application for loan repayment on a form provided by, including documentation of eligibility requirements, to the Virginia Physician Loan Repayment Program between the dates of January 1 and May 1 of the year in which the applicant intends to initiate practice in a medically underserved area. The applicant must agree to serve for not less than two years and up to four years, and the application shall be received in the department by July 31. The application form shall be available on the department's website.

12VAC5-508-70. Selection criteria.

Applicants shall be competitively reviewed and selected for participation in the Virginia Physician Loan Repayment Program based upon the following criteria:

1. Commitment to serve. The individual's stated commitment to serve in a designated medically underserved area of Virginia an HPSA, a VMUA, an approved geriatrics fellowship, or in a state or local institution.

2. Virginia residents/graduates residents or Virginia graduates. Preferential consideration will shall be given to individuals who are or have been Virginia residents, or graduates of Virginia medical schools (verification will shall be obtained by the Virginia Physician Loan Repayment Program), or natives of rural or designated medically underserved areas.

3. Residents of HPSAs or VMUAs. Preferential consideration shall be given to individuals who reside in HPSAs or VMUAs (verification shall be obtained by the Virginia Physician Loan Repayment Program).

3. 4. Availability for service. Individuals who are immediately eligible and available for service will shall be given higher consideration.

4. 5. Length of proposed commitment. Preferential consideration will shall be given to individuals who commit to longer periods of service.

5. 6. Selection for participation. All of an individual's professional qualifications and competency to practice in an underserved area will shall be considered, including board eligibility or specialty certification, professional achievements, and other indicators of competency received from supervisors, program directors, or other individuals who have agreed to enter into an employment contract with the individual.

6. No other obligations. Individuals shall have no other obligation for health professional service to the federal government or state government unless such obligation will be completely satisfied prior to the beginning of service under the Virginia Physician Loan Repayment Program.

12VAC5-508-75. Loans qualifying for repayment.

A. Based on the availability of funds, the loan repayment program shall pay for the cost of education necessary to obtain a medical degree. The program shall pay toward the outstanding principal, interest, and related expense of verifiable federal, state, or local government loans and commercial loans obtained by the participant for:

1. Tuition expenses; and

2. Other reasonable educational expenses.

B. All loan repayment awards shall be applied only to outstanding educational loans secured while attending an accredited medical school. Qualifying outstanding educational loans shall:

1. Have sufficient documentation verifying the educational use of the loans;

2. Not exceed the "reasonable" levels as determined by the school's standard budget in the year the loan was made; and

3. Not include loans from friends and relatives.

C. The department shall be the final authority in determining qualifying educational loans.

12VAC5-508-80. Loan repayment amount terms.

The amount that the Commonwealth agrees to repay will depend upon availability of funds and the applicant's indebtedness, but no amount will exceed the total indebtedness. For each year of participation, the Commonwealth will repay loan amounts according to the following schedule: two years of service will receive up to $50,000 (minimum requirement); three years of service will receive up to $85,000; and four years of service will receive up to $120,000.

A. Repayment of loans shall begin after the commissioner has received notification that the participant has officially accepted placement and has begun the required service obligation.

B. The applicant shall agree to serve a minimum of two years for a loan repayment amount of up to $60,000 with an option for a renewal in the third and fourth years. Renewals shall only be granted if the applicant can show a reduction in his educational loan balances. The loan repayment amount shall depend upon availability of funds and the applicant's indebtedness. In no event shall the amount of the loan repayment exceed the total indebtedness.

C. Payment shall be a lump-sum payment. Payment shall be made to the participant. A participant shall be paid one lump sum payment of up to $60,000 the first year for the minimum two-year commitment.  If a participant commits to a service obligation greater than two years, he shall be paid a lump sum payment of up to $40,000 each following year depending on the availability of funds.

D. The maximum number of years of participation in the loan repayment program to which a participant may commit is four years. Verification of payment made to the lender shall be required and submitted to the department. It shall be the responsibility of the participant to negotiate with each lending institution the terms of the educational loan repayments.

12VAC5-508-90. Loans qualifying for repayment. (Repealed.)

Based on the availability of funds, the loan repayment program will pay for the cost of education necessary to obtain a medical degree. The program will pay toward the outstanding principal, interest, and related expense of federal, state, or local government loans (not to include repayment of the Virginia Medical Scholarship Program) and commercial loans obtained by the participant for:

1. School tuition and required fees incurred by the participant;

2. Other reasonable educational expenses, including fees, books and laboratory expenses; and

3. Reasonable living expenses.

12VAC5-508-100. Repayment restrictions. (Repealed.)

A. The following financial debts or service obligations are not qualified for repayment by the loan repayment program:

1. Public Health Service Physician Shortage Area Scholarship;

2. Public Health and National Health Service Corps Scholarship Training Program;

3. Indian Health Service Scholarship Program;

4. Armed Forces Health Professions Scholarship Programs;

5. National Health Service Corps Scholarship Program financial damages or loans obtained to repay such damages;

6. Indian Health Corps Scholarship or loans obtained to repay such damages;

7. Financial damages or loans obtained to repay damages incurred as a result of breach of contract with any other federal, state, local agency or commercial institution;

8. Loans for which documentation verifying the educational use of the loans is not available or is not sufficient;

9. Loans or part of loans obtained for educational or personal expenses during the participant's education that exceed the "reasonable" level, as determined by the school's standard budget in the year the loan was made;

10. Loans that have been repaid in full, and loans that incur their own obligation for service which has not yet been performed;

11. Loans from friends and relatives; and

12. The Virginia Medical Scholarship Program.

B. The Department of Health will be the final authority in determining qualifying educational loans.

12VAC5-508-110. Release of information.

A. Applicants shall agree to execute a release of information to allow the board department access to loan records, credit information, and information from lenders necessary to verify eligibility and to determine loan repayments. To facilitate the process, applicants should shall submit pay-off payment statements from each lending institution.

B. Participants who have consolidated qualifying loans with other loans may be asked to shall submit upon request other documentation, such as copies of original loan applications, to verify the portion of the loan that qualifies for repayment.

C. The applicant is required to shall submit all requested loan documentation prior to approval by the Commonwealth department.

12VAC5-508-120. Service obligation sites Practice site.

All sites eligible for a participant's loan repayment participation will service obligation shall be located in a designated medically underserved area of the Commonwealth an HPSA, a VMUA, an approved geriatrics fellowship, or in a state or local institution. All placements must be to an approved entity providing primary health care within the designated VMUA or HPSA or a state or local institution. Each applicant will be provided with The department shall publish a list of preapproved areas on the department's website.

12VAC5-508-130. Effective date for start of service.

Applicants shall become participants in the loan repayment program only when the applicant and the commissioner or his designee have signed the loan repayment program contract. The effective start date of the obligated service under the contract is the date of employment or the date of the commissioner's signature on the contract, whichever is later.

If the contracted participant fails to begin or complete the period of professional practice to which he has agreed, the participant will be subject to the financial damages specified in the contract.

12VAC5-508-135. Terms of service.

The following are the terms of service for the loan repayment program:

1. The participant shall contract to provide a minimum of two years of the required service with a maximum of four years in whole year increments. Additional service beyond the two-year commitment is dependent upon the availability of state funds for the Virginia Physician Loan Repayment Program. An existing contract may be renewed for one year at a time up to a maximum of four years, as funds become available.

2. The participant shall provide full-time service.

3. No period of internship, residency, or other advanced clinical training, except an approved geriatrics fellowship, may count toward satisfying a period of obligated service under this loan repayment program.

12VAC5-508-140. Repayment policy. (Repealed.)

It will be the responsibility of the participant to negotiate with each lending institution for the terms of the educational loan repayments. Each lending institution must certify that the participant's debt is a valid educational loan prior to payment by the loan repayment program. Any penalties associated with early repayment shall be the responsibility of the participant.

12VAC5-508-150. Disbursement procedure. (Repealed.)

In an effort to assist loan repayment participants in reducing their educational debt with as little interest expense as is possible, the Virginia Physician Loan Repayment Program will disburse the funds in a lump sum payment. A participant will be paid one lump sum payment up to $50,000 the first year for the minimum two-year commitment within 45 days of execution of the contract. If a participant commits to a service obligation greater than two years, he will be paid a lump sum payment up to $35,000 the following year depending on availability of funds, approximately 45 days after the beginning of the subsequent year. The maximum number of years to which a participant can commit is four years.

12VAC5-508-160. Compensation during service.

Each participant is shall be responsible for negotiating his own compensation package directly with the site where he will provide primary health care services.

12VAC5-508-165. Conditions of practice.

A. The participant shall agree to provide health services without discrimination, regardless of a patient's ability to pay. Payments from Medicare and Medicaid shall be accepted by the designated practice site.

B. The participant shall agree to comply with all policies, rules, and regulations of the designated practice site.

12VAC5-508-170. Tax implications. (Repealed.)

Loan repayments are income and, therefore, are taxable by the United States Internal Revenue Service. It will be the responsibility of each participant to report the loan repayment award when preparing his tax return. Program participants should consider working with a qualified tax advisor regarding this matter.

The department will provide a form 1099 to applicants awarded loan repayment.

12VAC5-508-175. Change of practice site.

Should any participant find that he is unable to fulfill the required service commitment at the practice site to which he has committed to practice, he may request approval of a change of practice site. Such requests shall be made in writing. The commissioner in his discretion may approve such a request. All practice sites, including changes of practice sites, shall be selected with the approval of the commissioner.

In the event of a dispute between the participant and the practice site, every effort shall be made to resolve the dispute before reassignment will be permitted.

12VAC5-508-180. Monitoring during service.

Monitoring of the participant's service by participants obligation shall be conducted on an ongoing basis by department staff. Service verification forms will shall be submitted by the participant to the department semi-annually (every six months), and countersigned by a representative of the service site, to include, but not limited to, a (e.g., the medical director, human resource coordinator, or chief executive officer), certifying continuous full-time service by the participant.

The participant is required to shall maintain practice records in a manner that will allow the department to readily determine if the individual has complied with or is complying with the terms and conditions of the participation agreement contract. Department staff reserves the right to conduct a regular survey to ensure that all participants are maintaining practices that accept Medicare and Medicaid assignment and do not discriminate based on the patient's ability to pay.

12VAC5-508-190. Change of practice site. (Repealed.)

Should any participant find that he is unable to fulfill the service commitment at the loan repayment site to which he has committed to practice, he may be placed in breach of contract status or he may be expected to continue service at another approved loan repayment site within six months from departure from the previous site. This site will be selected in consultation with the participant and with the approval of the commissioner.

In the event of a dispute between the participant and the site, every effort will be made to resolve the dispute before reassignment will be permitted.

12VAC5-508-200. Terms of service. (Repealed.)

The following are the terms of service for the loan repayment program:

1. The participant shall contract to provide a minimum of two years with a maximum of up to four years in whole year increments. Additional service beyond the two-year commitment is dependent upon the availability of state funds for the Virginia Physician Loan Repayment Program. An existing contract may be renewed for one year at a time up to a maximum of four years, as funds become available;

2. The participant shall begin service within 12 months from entering into the contract;

3. The participant shall provide full-time service of at least 40 hours per week for 45 weeks per year to allow for continuing education, holidays, and vacation. The minimum 40-hour week must not be performed in less than four days per week, with no more than 12 hours of work performed in any 24-hour period. Time spent in an "on-call" status will not count toward the 40-hour week. Any exceptions to the "on-call" provisions of this section must be approved in advance by the commissioner prior to placement.

4. No period of internship, residency, or other advanced clinical training may count toward satisfying a period of obligated service under this loan repayment program.

12VAC5-508-210. Conditions of practice. (Repealed.)

A. The participant must agree to provide health services without discrimination regardless of a patient's ability to pay. Payments from Medicare and Medicaid must be accepted by the designated service site.

B. The participant must agree to comply with all policies, rules, and regulations of the designated service site.

Part III
Contract

12VAC5-508-220. Loan repayment contract.

Prior to becoming a participant in the Virginia Physician Loan Repayment Program, the applicant shall enter into a contract with the commissioner agreeing to the terms and conditions upon which the loan repayment is granted. The contract shall:

1. Include the terms and conditions to carry out the purposes and intent of this program;

2. Provide that the participant will shall be required to (i) provide primary health care services at an approved site in a designated medically underserved area an HPSA, a VMUA, or in a state or local institution for a minimum period of two years or (ii) be employed in an approved geriatrics fellowship for a minimum of two years. A four-year commitment is required in order to be eligible for the maximum amount of loan repayment, depending upon availability of funds. All loan repayment program participation will shall be contingent upon continuous, full-time practice in a medically underserved area of Virginia an HPSA, a VMUA, an approved geriatrics fellowship, or in a state or local institution; and

3. Provide for repayment of all amounts paid, plus interest, and penalties, less any service time, as set out in the contract in the event of breach of the contract;

4. Be signed by the applicant; and

5. Be signed by the commissioner or his designee.

12VAC5-508-230. Breach of contract.

A. The following may constitute breach of contract:

1. Participant's failure to begin or complete his term of obligated service under the terms and conditions of the Virginia Physician Loan Repayment Program contract, regardless of the length of the agreed period of obligated service;

2. Participant's falsification and/or or misrepresentation of information on the program application or verification forms or other required documents; or

3. Participant's employment being terminated Termination of participant's employment for good cause, as determined by the employer and confirmed by the department. If employment is terminated for reasons beyond the participant's control (e.g., closure of site), the participant must shall transfer to another approved site in a designated medically underserved area an HPSA, a VMUA, an approved geriatrics fellowship, or in a state or local institution within six months of termination. Failure of the participant to accept such find a transfer site within this time limit shall be deemed to be a breach of the contract; and.

4. Participant's failure to provide all reasonable, usual and customary full-time health care service for at least 45 weeks per year.

B. In the event of a breach of contract, the participant shall make default payments as described in 12VAC5-508-260 and in accordance with the terms of the contract. In the event of a breach of contract where the participant has partially fulfilled his obligation, the total amount of reimbursement shall be prorated by the proportion of obligation completed.

12VAC5-508-240. Collection procedure. (Repealed.)

If any person who has received funds and has been declared in breach of contract under this program at any time becomes an employee of the Commonwealth or any of its agencies, he shall be deemed to have agreed, as a condition of employment, to voluntarily or involuntarily have his wages withheld to repay the default damages.

Failure of a participant to make any repayment of the penalty when it is due shall be cause for the commissioner to refer the debt to the Attorney General of the Commonwealth of Virginia for collection. The recipient shall be responsible for any costs of collection as may be provided in Virginia law.

12VAC5-508-250. Waiver and suspension or both Deferment or waiver of service.

A. Participants have the obligation to complete full-time continuous service for the period of their entire commitment. Under unusual circumstances (e.g., illness) as described in subsection B of this section, a participant may request that the commissioner board agree to a postponement deferment of the service obligation. This postponement deferment, if granted, will shall not relieve the participant of the responsibility to complete the remaining portion of the obligation. Such postponement will deferment shall not be permitted as a matter of course, but may be allowed in the most compelling cases.

Waiver of the default provisions may be considered if the participant suffers from a physical or mental disability that occurs after the participant's commitment and results in the total and permanent inability of the participant to perform the obligated service (as determined by the commissioner), or if the participant dies during the period of obligated service.

B. Individual cases may be considered by the board for a variance of payment or service, pursuant to § 32.1-12 of the Code of Virginia, if it finds compliance with the applicable service requirements or default repayment would pose an undue hardship on the participant.

C. If the participant is in default due to death or disability so as not to be able to engage in medical practice in an HPSA, a VMUA, an approved geriatrics fellowship, or a state or local institution in the Commonwealth, the participant or his personal representative may be relieved of his obligation under the contract to engage in medical practice, upon repayment to the Commonwealth of the total amount of loan repayment received plus interest and penalty as stated in the contract. For participants completing part of the required service obligation prior to becoming permanently disabled or in the event of death, the total amount of loan repayment funds owed shall be reduced by the proportion of obligated years served. The obligation to make restitution may be waived by the board upon application of the participant or the participant's representative to the board.

D. All requests for deferments, waivers, or variances must be submitted in writing to the department for consideration and final disposition by the board.

12VAC5-508-260. Cash reimbursement and penalty.

Regardless of the length of the agreed period of obligated service, participants Participants who serve less than the two-year minimum (but at least one year) are their obligated service shall be liable to pay monetary damages for repayment, including interest and penalty, to the Commonwealth of Virginia as stated in the contract, reduced by the proportion of obligated years served. The default penalty will require the participant to repay twice the total amount of the award received. (For example, if a recipient owes $50,000, he would have to repay a total of $100,000.)

Part IV
Records and Reporting

12VAC5-508-270. Reporting requirements.

Reporting requirements of the loan repayment participant are as follows:

1. Each participant shall at any time provide information as required by the commissioner department to verify compliance with the practice requirements of the Virginia Physician Loan Repayment Program, e.g., verification of employment, see 12VAC5-508-180.

2. Each participant shall promptly notify the commissioner department, in writing, within 30 days before of any of the following events occur:

a. Participant changes name;

b. Participant changes address;

c. Participant changes practice site;

d. Participant no longer intends or is no longer able to fulfill service obligation as a primary care health care provider in a designated medically underserved area an HPSA, a VMUA, an approved geriatrics fellowship, or a state or local institution; or

e. Participant ceases to practice as a physician.