Form Free Clinics 1 Free Clinics 1 Free Clinics Application

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Overview

Contact Information
Sponsoring Free Clinic
Credentialing - Privileging
Risk Management
Individuals
Signature Page

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Sheet 1: Contact Information

MEDICAL MALPRACTICE COVERAGE FOR INDIVIDUALS AT FREE CLINICS UNDER THE FEDERAL TORT CLAIMS ACT Original or Redeeming Application OMB No. 0915-0293 (To be completed for each annual deeming cycle) Please fill out this application completely and accurately. Applications cannot be processed until they are complete and include the required attachments and signature page from PAL 2011-09. Applications should be emailed as an excel file to freeclinicsFTCA@hrsa.gov. Please note that each section of the application has its own tab at the bottom. There are five (5) tabs to be completed. For each field of information, click on the accompanying empty box and fill in the appropriate answer. If you have any questions, please feel free to email HRSA at freeclinicsFTCA@hrsa.gov.
SECTION I - APPLICANT INFORMATION Enter contact and identifying information for the sponsoring free clinic
Free Clinic FTCA Number: (Leave blank if original deeming application)
Corporate Name of Free Clinic or Sponsoring Entity: (If there has been a legal name change since the last application submission, please attach the appropriate state document indicating the change.)
List any “doing business as” (dba) name:
Corporate Address:
Clinic Telephone Number:
Clinic Fax Number:
Chief Executive Officer’s Name:
CEO Direct Telephone Number:
CEO E-mail:
Medial Director’s Name:
Medical Director E-mail:
Primary FTCA Contact Name:
FTCA Contact Email:
FTCA Contact Direct Telephone Number:
Risk Management Coordinator’s Name:
Changes in name or address since last application:
SECTION II – FREE CLINIC SITES List all free clinic sites where volunteer health care professionals will be providing services. Add more fields as necessary.
Free Clinic Site—Main
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Executive Director’s Name:
Telephone Number:
Medical Director’s Name:
Telephone Number:
Free Clinic Site—Additional							(Copy and add more sites as necessary)
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Executive Director’s Name:
Telephone Number:
Medical Director’s Name:
Telephone Number:
PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0293. Public reporting burden for this collection of information is estimated to average 17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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Sheet 2: Sponsoring Free Clinic

SECTION III – SPONSORING FREE CLINIC ELIGIBILITY Please answer YES or NO to the following questions by marking in the appropriate box. “NO” answers require an explanation. For a covered individual to be deemed, they must be sponsored by an eligible free clinic.
Item	Yes /No	If No, Please Explain Here.
1.      The sponsoring free clinic is a registered nonprofit organization. (Please attach documentation if an Initial Applicant)
2.      The sponsoring free clinic and its health professionals comply with the statutory and Program definitions relative to covered individuals as set forth in PIN 2011-02.
3.      The free clinic does not accept reimbursement from any third-party payor (including but not limited to reimbursement from an insurance policy, health plan, or other Federal or State health benefits program).
4.      The free clinic does not impose charges on patients either based on service provided or the ability to pay.
5.      The free clinic accepts patients’ voluntary donations for services provided.
6.      The free clinic is licensed or certified to provide health services in accordance with applicable state law.
7.      The free clinic and/or individual health care professional provides a patient a written notification explaining that the patients’ legal liability is limited pursuant to the Public Health Service Act.
PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0293. Public reporting burden for this collection of information is estimated to average 17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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Sheet 3: Credentialing - Privileging

SECTION IV– CREDENTIALING AND PRIVILEGING SYSTEMS Please answer YES or NO to the following questions by marking in the appropriate box. “NO” answers require an explanation. Note that the credentialing and privileging activities specified below may be done through the free clinic’s own efforts or through its reasonable reliance on information provided to it by a credible third party such as a credentialing verification organization.
Item	Yes/No	If No, Please Explain Here.
1.      The free clinic periodically verifies licensure, certification and/ or registration of each volunteer health care professional according to the instructions in this PIN 2011-02.
2.      The free clinic has a copy of each volunteer health care professional’s current license, and/or registration on file at the free clinic.
3.      The free clinic periodically verifies board eligibility or certification for each volunteer health care professional, when applicable, according to instructions in this PIN 2011-02.
4.      If the free clinic uses a hospital to serve as a CVO, there is a written contractual agreement stating the specifics of the expected CVO services.
5.      The free clinic utilizes peer review activities when it periodically privileges volunteer health care professional according to the instructions in this PIN 2011-02.
6.      The free clinic has a copy of each volunteer health care professional’s hospital privileges, when applicable, on file.
7.      The free clinic annually reviews each volunteer health care professional’s history of prior and current medical malpractice claims.
8.      During the credentialing process of covered individuals, the free clinic queries the National Practitioner Data Bank according to the instructions in this PIN 2011-02.
PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0293. Public reporting burden for this collection of information is estimated to average 17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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Sheet 4: Risk Management

SECTION V – RISK MANAGEMENT SYSTEMS Please answer YES or NO to the following questions by marking in the appropriate box. “NO” answers require an explanation. In addition, a copy of the Quality Assurance plan should be sent as an attachment along with this application. It must have been approved by the board within three (3) years of this application.
Item	Yes/ No	If No, Please Explain Here.
1.      The free clinic has policies and procedures in place for the provision of appropriate supervision and back-up of clinical staff.
2.      The free clinic maintains a medical record for those receiving care from its organization.
3.      The free clinic has policies and procedures that address triage, walk-in patients and telephone triage.
4.      The free clinic has protocols that define appropriate treatment and diagnostic procedures for selected medical conditions based on current standards of care.
5.      The free clinic has a tracking system for patients who miss appointments or require follow-up of referrals, hospitalization, x-rays, or laboratory results.
6.      The free clinic periodically reviews patients’ medical records to determine quality, completeness and legibility.
7.      The free clinic has a written, current quality assurance plan (please attach a copy of the plan with board approval date, if any changes have been made since the first submission).
8.      The free clinic has regular, periodic meetings to review and assess quality assurance issues.
9.      The free clinic considers findings from its peer review activities when reviewing and/or revising its quality assurance plan.
10.  The free clinic utilizes quality assurance finding to modify policies to improve patient care.
11.  The free clinic’s volunteer health care professionals annually participate in risk management continuing education activities.
12.  The free clinic has assured that each volunteer health care professional has a copy of PIN 2011-02, and that his/her questions regarding FTCA medical malpractice coverage have been addressed.
PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0293. Public reporting burden for this collection of information is estimated to average 17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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Sheet 5: Individuals

SECTION VI – FREE CLINIC VOLUNTEER HEALTH CARE PROFESSIONALS, BOARD MEMBERS, OFFICERS, EMPLOYEES, AND INDIVIDUAL CONTRACTORS List of ALL volunteer free clinic licensed or certified health care professionals, board members, officers, employees, and individual contractors that the free clinic wants to sponsor for FTCA deemed status. Remember that credentialing must have been done within the past two (2) years. For Renewal Applications, also stipulate if the person is a currently deemed covered individual to be continued as deemed for the next year or if the individual to be added. Please report all medical malpractice claims against any volunteer health care professional, board member, officer, employee, and individual contractor. If there have been any suits, attach a file explaining the suit, date of suit and incident, the medical specialty involved, the allegation, and whether any action was taken by the free clinic to prevent such claims in the future. Also include a list of any disciplinary actions taken by a State medical licensing authority (or a professional society). Report claims or actions for the previous ten (10) years for new applicants and for the previous five (5) years for renewal applicants.

First Name

Last Name

Professional designation (e.g., MD, RN, CNM)

Home Address

State

Zip

Home Phone

Role or Roles in Free Clinic

Specialty Training

Specialty to be Practiced at the Free Clinic

Date of Last Credentialing

Date of Last Priviledging

Person and Organization Conducting Credentialing/Privileging

Any medical malpractice claims against the person?

Is this person a new applicant, renewal applicant, or to be dropped from coverage?

PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0293. Public reporting burden for this collection of information is estimated to average 17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

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Sheet 6: Signature Page

SECTION VII - SIGNATURE PAGE

Once the application has been finished, your application should include an scanned version of this signed and executed page and emailed to the Bureau of Primary Health Care along with the application to freeclinicsFTCA@hrsa.gov. Renewal applicants may type their names as an electronic signature. Initial applicants must submit actual signatures.

SECTION VII – SIGNATURES

REQUESTED EFFECTIVE DATE OF FTCA COVERAGE ______________________

(No sooner than 30 days from the date of application submission. Renewal coverage will begin the first of the year.)

We certify that this sponsoring free clinic meets the definition of a free clinic found in Section III of HRSA/BPHC PIN 2011-02 and that the information in this application and the related attachments is complete and accurate.

CHIEF EXECUTIVE OFFICER

Name (Print or type): ___________________________

Signature Date

FREE CLINIC MEDICAL DIRECTOR

Name (Print or type): ___________________________

Signature Date