Rural Health Workforce Incentive Program

Rural Health Workforce Incentive Program - Health Professional Application

Please complete the application below.

Read the Frequently Asked Questions (opens in a new tab) before completing this application or submitting questions regarding this program.

Application Deadline: June 30, 2026 11:59PM CDT

Note: Once you begin to fill out this form, a record is created. If you are unable to complete the application in one sitting, use the Save and Return button at the bottom. Be sure to save the code that is generated so you can access your application when you return to it. Use the Returning button in the top righthand corner to get back to your application. If you need assistance with the access code, email dhhs.ruralhealth@nebraska.gov but DO NOT CREATE MULTIPLE RECORDS.

All fields marked with asterisk are required.

Personal Information

First Name

Middle Name

Last Name

Maiden Name

Contact Information

Email Address (Contract will be sent to this address)

Phone Number

Address

City

State

Zip Code

Health Profession Information

National Practitioner Identifier Number (if applicable)

Profession (If you do not see your profession, you are not eligible for the Program)

License Status

Licensed or Provisionally Licensed

Not Licensed

Employer & Practice Site Information

Which best describes your rural work status?

Being recruited to a rural practice site or an expanded rural practice site

Being retained in an existing role/practice

Employer 1

Employer Name

Contact Name

Employer Email

Practice Sites (Only practice sites located in Rural Nebraska are eligible)

Applicants must start practice at this site on or before August 1, 2026.

Practice Site 1

Site Name

Address

County

City

Zip Code

Number of hours per week

Total number of hours per week: 0

Annual Award Amount: —

Medicaid/uninsured patient requirement:

Year 1: 5% Medicaid (baseline)
Year 2: 5% Medicaid + 2% Medicaid or uninsured (7% total)
Year 3: 5% Medicaid + 4% Medicaid or uninsured (9% total)
Year 4: 5% Medicaid + 6% Medicaid or uninsured (11% total)
Year 5: 5% Medicaid + 8% Medicaid or uninsured (13% total)

I agree to accept Medicaid patients according to the requirement above

Disclaimer: Acceptance of Medicaid patients is subject to verification

Are you currently participating in a Federal or State Loan Repayment Program?

Yes

In one paragraph or less, please tell us why you wish to work or continue to work in rural Nebraska.

Document Attachments

Click on this link to open the W-9 & ACH enrollment form: W9/ACH Enrollment Form (opens in a new tab)

Complete, sign, and date the form, save, and upload it here. Use your personal information, fill out all required fields, and sign in both areas (middle and bottom of the form).

Upload guidelines: One file per upload. Accepted formats: .pdf, .jpg, .jpeg, .png. File names must be 200 characters or fewer and can only contain letters, numbers, spaces, hyphens (-), and underscores (_).

Upload W-9/ACH Enrollment Form

Upload Blank/Voided Check

United States Citizenship Attestation

For the purpose of complying with Neb Rev. Stat. §§ 4-108 through 4-114, I attest as follows:

Citizenship Status

I am a citizen of the United States

I am a qualified alien under the federal Immigration and Nationality Act

Signature

I hereby attest that my response and the information provided on this form and any related application for public benefits are true, complete, and accurate. I understand that this information may be used to verify my lawful presence in the United States.

Signature

Today's Date: 04/17/2026

Your application has been saved.

Please save the following access code. You will need it to return and complete your application.

Do not lose this code. Write it down or save it somewhere safe.