Conrad 30 in Montana, North Dakota and Wyoming: The J-1 Physician Waiver

You are a hospital or clinic in Montana, North Dakota or Wyoming, and the internist or hospitalist you want to hire is finishing a residency on a J-1. Or you are that physician, and you have just learned that your J-1 comes with a rule requiring two years back home before you can work in the United States on most visas or get a green card. Either way, someone has said “Conrad 30,” and you need to know what it is, whether it fits, and how long it takes.

Here is the short answer. Conrad 30 is a trade: a state health department asks the federal government to waive a J-1 physician’s two-year home-residency requirement, and in return the physician works full-time for three years at a named facility that serves a federally designated shortage area. Each state may request up to 30 of these waivers a year, and up to 10 of them may go to facilities outside a shortage area if they serve patients who live in one. The state recommends, the State Department reviews, USCIS decides, and the physician then works on an H-1B that is not subject to the annual H-1B lottery. Most of the details that decide a real case are set by each state, not by federal regulation, so Montana, North Dakota and Wyoming each run the program a little differently. This page explains the federal rules, how the three states apply them as of October 29, 2026, and where cases go wrong.

What is Conrad 30?

Conrad 30 is the state-sponsored route to waive the two-year home-residency requirement for a physician who trained in the United States on a J-1. It takes its name from former Senator Kent Conrad of North Dakota, and the “30” is the number of waivers each state may request in a federal fiscal year (October 1 through September 30). The rules are in section 214(l) of the Immigration and Nationality Act.

The bargain is simple to state. The physician gives three years of full-time clinical work where the country is short of doctors. In exchange, the home-residency requirement goes away, and the physician can later seek a green card without first spending two years abroad. Every state gets the same 30, whether it is California or Wyoming, which is one reason the program matters more to rural states than to large ones.

Which physicians need a Conrad 30 waiver?

Any physician who came to the United States on a J-1 for graduate medical education or training, meaning a residency or fellowship sponsored by ECFMG (the Educational Commission for Foreign Medical Graduates), is subject to the two-year home-residency requirement in INA § 212(e). It does not matter where the physician is from or who paid for the training. Graduate medical training is one of the three statutory triggers, and for these physicians it always applies. Our page on whether you are subject to the two-year rule explains all three triggers.

Two consequences shape everything else. First, the easiest waiver for other J-1s, a “no objection” statement from the home government, is not available to a physician who came for graduate medical training (8 CFR 212.7(c)(11)). The no-objection statement does reappear in one place: a physician who is contractually obligated to return home, for example because the home government funded the training, must include one with a Conrad request (INA § 214(l)(1)(A)). Second, a J-1 physician cannot change to another status from inside the United States. USCIS’s Conrad 30 page notes the narrow exceptions; the one that matters here is the H-1B change of status that the statute allows only after a Conrad or federal-agency waiver. So for most J-1 physicians who want to stay and practise, the realistic waiver routes are Conrad 30, a federal agency request, or a hardship or persecution waiver. The full list of waiver bases is in our guide to the five J-1 waivers.

How does a Conrad 30 waiver work, step by step?

A Conrad 30 case moves through three offices in a fixed order, and the hospital and the physician each have work to do at every stage.

1. The employment contract. The facility and the physician sign a full-time contract for at least three years at a named facility. The state reviews it closely, so it has to be right before anything is filed (see the next section).
2. The state application. The facility, usually through its attorney, files the state’s own application with the state’s primary care office, which runs the program for the state health department. Each state sets its own forms, documents, priorities and timing.
3. The State Department. The physician completes Form DS-3035 online, which opens a case with the State Department’s Waiver Review Division, and pays the State Department’s processing fee. When the state agrees to sponsor the physician, it sends its request and supporting file to the Waiver Review Division, which decides whether to recommend the waiver.
4. USCIS. The State Department sends a favorable recommendation to USCIS electronically. Put in plain terms, USCIS says it will generally grant the waiver after a favorable recommendation unless it has some other concern. No separate Form I-612 is needed.
5. The H-1B. The facility files Form I-129 to change the physician from J-1 to H-1B, with the State Department’s recommendation letter; a spouse and children file Form I-539 to change from J-2 to H-4. This H-1B is not subject to the annual cap and lottery (INA § 214(l)(2)(A)). Our H-1B guide covers the H-1B itself.
6. Start within 90 days. The physician must agree to begin work within 90 days of receiving the waiver (not 90 days from the end of the J-1), and must then complete three years. Plan a start date that can realistically meet that commitment.

The three stages run one after another, so start early. The training year ends on June 30, many states open their applications on or soon after October 1, and the federal stages take time after that. A physician who starts this conversation in the final spring of residency has usually started late.

What must the Conrad 30 employment contract say?

The contract has to be a bona fide offer of full-time employment at a health facility, for at least three years, at a site that serves a federally designated shortage area. In practice, a contract that will survive state and federal review has these features:

• Full-time means 40 hours a week. USCIS says the State Department treats “full-time” as 40 hours per week. Montana’s policy adds that the 40 hours must be direct patient care.
• A three-year term and a named place of work. The contract names the facility and every address where the physician will practise. North Dakota’s guidelines require each work address to be listed and bar changes to essential terms without the state’s approval.
• A start date that fits the 90-day rule. The physician must agree to start within 90 days of the waiver.
• Termination only for cause. An at-will contract that either side can end on short notice is a poor fit for a three-year statutory commitment. The federal Department of Health and Human Services, when it is the requesting agency, requires that the contract be terminable before three years only for cause and forbids a non-compete that would keep the physician from practising in a shortage area afterward (45 CFR 50.5). States apply their own versions of these rules, so check the state’s guidelines for the exact wording.
• A described practice. Montana’s policy asks that the contract state the types of medical services and define their scope, frequency and location.

The contract binds both sides in a way an ordinary employment agreement does not. The hospital is committing to keep a physician for three years, and the physician is committing to stay. When that commitment fails, the immigration consequences fall mostly on the physician, which is why the contract deserves more care than a standard recruitment offer.

What is a Conrad 30 “flex” slot?

A flex slot lets a state recommend a physician for a facility that is not itself in a shortage area, as long as the facility serves patients who live in one. The statute caps flex slots at 10 of the state’s 30 each year (INA § 214(l)(1)(D)(ii)). The other 20 are not reserved for primary care by federal law. A specialist can use a regular slot at a facility inside a shortage area if the state finds, under its own criteria, a shortage in that specialty for the patients the physician will serve (§ 214(l)(1)(D)(iii)). The common description of the program as “20 primary care slots plus 10 flex” is a simplification; how a state actually divides its 30 is the state’s choice.

Flex slots were written for the regional referral hospital. In eastern Montana, many counties can support a clinic and a family physician but not a cardiologist or an oncologist, so patients travel to a regional center such as Billings for anything beyond primary care. The referral hospital may not sit in a shortage area, but much of its patient base comes from places that do. When I prepared flex requests for a regional hospital, I asked for anonymized patient-origin data for the department that was hiring, and the share of patients from shortage areas was sometimes well over half. That is a stronger and more candid case than relying on a designation alone.

Designations themselves can surprise people. The Health Resources and Services Administration designates Health Professional Shortage Areas (HPSAs) of three kinds: geographic areas, population groups (for example, low-income residents of an area) and particular facilities. A low-income population designation can cover part of a city that has several hospitals, and a facility inside it can use a regular slot rather than a flex slot. HHS also designates Medically Underserved Areas and Populations (MUA/Ps), which federal guidance treats as qualifying too. Whether a site qualifies, and on what basis, is a lookup in HRSA’s HPSA Find and MUA Find tools for the specific address, confirmed against what the state accepts, not a guess based on how rural the area feels.

How do Montana, North Dakota and Wyoming run Conrad 30?

Each state publishes its own guidelines, and they differ in how they rank applications and what they require. The table reflects the documents each state had posted as of October 29, 2026; check the current version before filing.

In my experience with Montana, flex slots have been fully used only once, and demand for regular shortage-area slots has often been light, so timing has mattered less here than in large states where 30 slots are gone on the first day. That can change in any year, and a complete application filed early is still the safest plan. Other states use other methods: some take applications strictly in order from October 1, some fill primary care first and give specialists what is left, and some score applications by need. A physician choosing between jobs in different states is also choosing between these systems.

Why is so little of Conrad 30 written down in federal rules?

Because the federal government left most of it to the states, and never updated its own regulation. The statute sets the frame: 30 per state, 10 flex, three years, 90 days, a shortage area and a cap-exempt H-1B. The USCIS regulation, 8 CFR 212.7(c)(9), still describes the program as it stood in the late 1990s: it caps waivers at 20 per state, says the resulting H-1B is subject to the annual cap, and limits eligibility to physicians who held J status before June 1, 2002. Congress has since amended the statute on each of those points, and where the regulation and the statute disagree, the statute controls. Everything else, such as application windows, priorities, specialty rules, contract terms and reporting, comes from each state’s guidelines and the practice of its primary care office.

That has a practical consequence for the physician and the hospital. Many questions that look like legal questions (“can we use a flex slot for a hospitalist?”, “what happens if the clinic moves?”) are answered by the state office’s reading of its own guidelines, and offices sometimes look to how other states handle the same question. A Conrad case goes best when the facility, the physician and their lawyer work with the state office rather than around it.

Is Conrad 30 still available?

Yes. Conrad 30 has never been permanently authorized. Since 1994 Congress has kept it alive by renewing it, usually in spending bills, and it has always come back, with only short gaps. The Consolidated Appropriations Act, 2026 extended it to September 30, 2026 (Pub. L. 119-75, div. I, § 5013), and the continuing resolution enacted on September 2, 2026 carries that provision forward to December 11, 2026 (Pub. L. 119-103, §§ 101(6) and 106). As of October 29, 2026, that is the current extension.

A lapse does not end the program for everyone. The expiration date applies to physicians by the date they entered or acquired J-1 status. During the October 2025 government shutdown, USCIS explained that physicians who were admitted in, or acquired, J-1 status on or before September 30 remained eligible, while those first admitted in J-1 status during the lapse were not, unless Congress extended the program. A physician already in residency is therefore usually protected even if a deadline passes, but a lapse is a real risk for anyone whose J-1 status begins during one. Check the status of the program at the time you plan.

What happens if a Conrad 30 job ends before three years?

The waiver is granted up front, but it is earned by completing the service. If a physician leaves the facility before three years are up without USCIS approval, the two-year home-residency requirement comes back, and the physician cannot get an immigrant visa, a green card or another change of status until it is satisfied (INA § 214(l)(2)(B) and (3)). The facility named in the waiver must also tell USCIS promptly if it no longer employs the physician.

The statute does allow a change of facility when there are “extenuating circumstances,” such as closure of the facility or hardship to the physician. The route is a new H-1B petition by the new employer, filed with USCIS. The state does not need to file a new waiver request. Put in plain terms, the regulation and USCIS’s guidance require the new petition to include a copy of the waiver approval, the physician’s explanation with evidence of the extenuating circumstances, a contract with the new facility for the rest of the three years, and proof that the new site is in a designated shortage area or, in some cases, serves patients from one. USCIS says the physician may start at the new facility once the new petition is filed, but if it is denied, the work authorization stops and the two-year requirement returns (8 CFR 212.7(c)(9)(iv)–(vi); USCIS Conrad 30 FAQ).

Extenuating circumstances are not limited to a closed clinic. I have handled two mid-term moves of this kind. In one, the facility let the physician go because it said his billing did not cover his cost; in the other, the job turned out to be materially different from what the contract and the recruiter had described. In both cases the new H-1B was approved without a request for evidence. What made those cases work was a documented showing that the original facility had not lived up to the agreement, in its terms or in practice, and a new contract that met every Conrad requirement. These moves usually go directly to USCIS; the state office may or may not be involved, depending on the state and the circumstances.

What other waiver routes does a J-1 physician have?

Conrad 30 is the most common route, but not the only one.

• A federal agency request. The statute allows an “interested Federal agency” to request a waiver on similar terms. The Department of Health and Human Services sponsors primary care physicians (internal medicine, pediatrics, family practice, obstetrics and gynecology) and general psychiatrists who finished residency no more than 12 months before the job starts and will practise in a primary care shortage area or MUA/P (a mental health shortage area for psychiatrists), under its own rules (45 CFR 50.5). A Department of Veterans Affairs request does not require a shortage area at all. A federal request does not use one of the state’s 30.
• Exceptional hardship or persecution. A physician married to, or the parent of, a U.S. citizen or permanent resident can seek a waiver based on exceptional hardship to that family member, and a physician who would be persecuted at home on account of race, religion or political opinion, a stricter test than asylum, can seek one on that ground. Both are filed with USCIS on Form I-612 and need a favorable State Department recommendation. They are slower and less certain than Conrad, and they carry no three-year service obligation, which matters to the hospital. I once represented a hospital that was partway through Conrad filings for two physicians when their hardship waivers came through first; both took positions elsewhere, and the Conrad work was lost. A hospital recruiting a physician with a pending hardship case should know about it.

A physician with a strong record of achievement may also consider the O-1 visa. The two-year requirement does not bar the O-1 visa itself, but the physician cannot change to O-1 from inside the United States after graduate medical training, so it means leaving and returning on a visa issued at a consulate, and O-1 time does not count toward a Conrad obligation. That route deserves advice before any plan is made around it.

What comes after the three years?

Once the three years are complete, the physician, and the spouse and children, can apply for a green card, an H visa or an L visa without the two-year requirement. Many physicians do so through their Conrad employer, either through PERM labor certification or through the physician National Interest Waiver, which requires five years of full-time clinical work in a shortage area. Conrad H-1B years generally count toward those five (8 CFR 245.18(e)(2)), but only if the work also met the National Interest Waiver’s own location and specialty rules; flex-slot service at a site outside a designated area may not count. Our page on the EB-2 National Interest Waiver explains the physician route and its timing.

Whether the physician stays after three years depends largely on the placement. Some facilities treat Conrad as three years of guaranteed staffing, with long hours and little reason to stay; physicians in those jobs tend to leave the day the obligation ends. Others treat it as the start of a long relationship: reasonable workloads, good colleagues, fair pay and a community the family wants to live in, followed by green card sponsorship. The second model costs more up front and is the one that keeps a physician in a rural community.

Where do Conrad 30 cases go wrong?

The cases that fail usually fail for ordinary reasons, and most of them can be avoided:

• Starting too late. State review, the State Department and USCIS take months, and the 90-day start commitment leaves little room at the end.
• The wrong slot. Filing a flex request for a site that qualifies for a regular slot, or the reverse, without checking the designation for the exact address.
• A contract that does not fit the program. At-will termination, missing practice sites, fewer than 40 hours of clinical work, or a non-compete that the state will not accept.
• Leaving early without USCIS approval. Changing employers before three years, even for good reasons, needs a new H-1B petition based on extenuating circumstances. Simply moving brings back the two-year requirement.

Conrad 30 works well when the hospital, the physician and the state office all treat the three years as a real commitment. Our firm has prepared Conrad 30 waivers for Montana hospitals for more than twenty years, and we also help physicians whose placements have gone wrong. If you are a facility recruiting a J-1 physician, or a physician weighing an offer in Montana, North Dakota or Wyoming, contact our office to talk through your timeline and the right slot for your site.