Impaired Physicians Loan

Loan Application Process

Here is the application form for the MSMS Foundation's loan program for impaired physicians, which may be able to assist you with expenses for rehabilitation. The process is confidential.

This process requires that you download and fill out the form and return it to our office via fax or mail. Staff will distribute copies to the Board members serving on our Impaired Physician Loan Fund Committee. They will review your request, and determine whether a loan is feasible, and if so, the size of the loan. Customarily the loans are sent directly to treatment programs rather than to individuals.

This loan application review process should take no more than one month. Again, it is a confidential process, with only the Committee members and the Foundation staff aware of the individuals who are applying.

We wish you well, and look forward to receiving your completed form.

Member Type

MSMS Member

Former Member

Other (specify)

Other Member

Date

Name of Applicant

Address

Current Street Address

City

State

ZIP Code

Telephone (home)

Telephone (other)

Loan Amount Requested ($5,000 maximum)

Nature of Impairment and Evaluation of Prospects for Recovery

Have you been in contact with the Michigan Health Professional Recovery Program (1-800-453-3784)?

Yes

Purpose of Loan

Desired terms of loan repayment

Check this box if you are willing to be personally interviewed about this loan application.