Free Clinics FTCA Program Application

Program Assistance Letter
DOCUMENT NUMBER: PAL 2010 - XX
DOCUMENT NUMBER: 2011-09
DATE: August 8, 2011

TO:

I.

DOCUMENT TITLE: Calendar Year 2012
Federal Tort Claims Act (FTCA) Deeming
Application for Free Clinics

Free Clinics
Free Clinic Associations
Primary Care Associations
Primary Care Offices
National Cooperative Agreements

PURPOSE
This Program Assistance Letter (PAL) supplements Program Information Notice (PIN) 201102, “Free Clinics Federal Tort Claims Act (FTCA) Program Policy Guide”
(http://bphc.hrsa.gov/ftca/freeclinics/) and provides guidance on the Calendar Year (CY)
2012 deeming application process for medical malpractice liability coverage under the
provisions of section 224(o) of the PHS Act and the Federal Tort Claims Act (FTCA). This PAL
contains instructions for free clinics on how to apply to HRSA for medical malpractice
coverage under the FTCA for CY 2012 on behalf of their volunteer free clinic health care
professionals, board members, officers, employees, and/or contractors. Redeeming
applications for CY 2012 coverage are due no later than September 16, 2011.
Medical malpractice coverage under the FTCA is provided to certain qualified free clinic
volunteer health care professionals, board members, officers, employees, and/or
contractors (covered individuals) under section 224(o) of the Public Health Service (PHS)
Act, as amended (42 U.S.C. 233(o)). PIN 2011-02 details the process through which the
United States Department of Health and Human Services’ (HHS) Health Resources and
Services Administration (HRSA) may deem a volunteer free clinic health care professional to
be a PHS employee for the purposes of FTCA coverage for medical malpractice claims if the
free clinic volunteer health care professional or other eligible individual meets certain
statutory and program requirements.

Program Assistance Letter 2011-09

Free clinics must submit an annual FTCA deeming application on behalf of their eligible
individuals to HRSA, which administers the Free Clinics FTCA Program. With the
amendment of PHS Act section 224(o) by the Affordable Care Act, free clinic board
members, officers, employees, and/or individual contractors, as well as volunteer health
care professionals, whose deeming applications are approved by HRSA, may be deemed as
PHS employees for purposes of FTCA medical malpractice coverage. FTCA coverage for free
clinic volunteer health care professionals, board members, officers, employees, and
individual contractors extends only to medical malpractice coverage for negligent acts and
omissions that arise from the performance of medical, surgical, dental or related functions
within the scope of the covered individual’s employment (i.e., work on behalf of the
sponsoring free clinic). Section 224(o) does not provide coverage beyond medical
malpractice liability protection. Free clinic coverage does not extend to free clinic entities
and therefore these entities are not eligible for coverage under PHS Act section 224(o).
II.

APPLICATION PROCEDURES
Medical malpractice coverage under the Free Clinics FTCA Program does not occur
automatically. FTCA coverage requires that HRSA approve a deeming application submitted
by a sponsoring free clinic on behalf of eligible individuals. Deeming applications can be
downloaded from http://bphc.hrsa.gov/ftca/freeclinics/. The applications are currently in
Microsoft Excel format. Completed applications must be submitted in this format (as an .xls
file). This PAL sets forth the process by which such deeming applications must be
submitted.
A. INITIAL APPLICATIONS
Free clinics must complete a deeming application in order to sponsor volunteer health
professionals, board members, officers, employees, and/or contractors for FTCA coverage.
Applications require that the appropriate free clinic representatives affix their signatures to
the signature page attached to this PAL, attach documentation of the sponsoring free
clinic’s nonprofit status, attach its quality improvement/quality assurance (QI/QA) plan, and
include an explanation of any medical malpractice claims or any disciplinary actions taken
against an eligible individual during the past ten (10) years. The required information must
be submitted as attachment files with the application form.
The original deeming application form requires a free clinic to provide information as
evidence that it has fulfilled statutory and programmatic requirements, including:
1) Contact information for the sponsoring free clinic;
2) Location and manager(s) of free clinic sites;
3) Confirmation that the sponsoring free clinic and individuals for whom deeming is
sought meet the statutory eligibility criteria;
4) Description of the free clinic’s credentialing and privileging systems;
5) Description of the free clinic’s risk management systems;
6) List of all individuals (i.e., volunteer health care professionals, board members,
officers, employees and individual contractors) whom the free clinic is sponsoring
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for deemed employment status;
7) Evidence that each licensed or certified individual was credentialed and privileged by
the sponsoring free clinic within the last two years, including the specific dates such
actions were taken; and
8) Requested effective date of FTCA coverage (which may not be less than 30 days
following submission of a complete application).
In addition to a complete application form, as noted above, an application will be
considered complete with all the following attachments:
a. Documentation of non-profit status;
b. Quality Improvement /Quality Assurance plan (QI/QA) with either a signature of an
authorized board representative indicating date of board approval or a copy of board
minutes documenting approval;
c. Description of any and all disciplinary actions and malpractice claims alleged against the
free clinic and/or its sponsored eligible individuals within ten (10) years prior to the
submission of this FTCA application (including pending claims), and a brief explanation
of risk management activities the free clinic has taken in response to allegations; and
d. Affirmation signatures by the Chief Executive Officer and Medical Director of the
sponsoring free clinic that all statements and assertions made by the application are
true under penalty of perjury.
HRSA will accept initial deeming applications at any time a free clinic and its eligible
individuals wish to pursue FTCA medical malpractice coverage. The application form can be
found at http://bphc.hrsa.gov/ftca/freeclinics/ entitled “Free Clinic Deeming Application.”
B. REDEEMING APPLICATIONS
Free clinics that currently sponsor deemed individuals must reapply annually for continued
FTCA coverage. The annual redeeming application form is the same application used for
original applicants. This application form can be found at
http://bphc.hrsa.gov/ftca/freeclinics/ and is entitled “Deeming Application.”
The re-deeming application form requires a free clinic to provide information to
demonstrate that it has fulfilled statutory and program requirements, including:
1) Contact information for the sponsoring free clinic;
2) Location and manager(s) of free clinic sites;
3) Confirmation that the sponsoring free clinic and individuals for whom deeming is
sought meet the statutory eligibility criteria;
4) Description of the free clinic’s credentialing and privileging systems;
5) Description of the free clinic’s risk management systems;
6) List of all individuals (i.e., volunteer health care professionals, board members,
officers, employees and individual contractors) whom the free clinic is sponsoring
for deemed employment status;
7) Evidence that each licensed or certified individual was credentialed and privileged by
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the sponsoring free clinic within the last two years, including the specific dates such
actions were taken; and
8) Requested effective date of FTCA coverage (which may not be less than 30 days
following submission of a complete application).
In addition to a complete application form, an application will not be considered complete
without the following attachments:
a. Quality Improvement /Quality Assurance plan (QI/QA) with either a signature of an
authorized board representative and date indicating date of board approval or a copy
of board minutes documenting approval (either method of submission must evidence
that approval was undertaken within the last three (3) years);
b. Description of any and all disciplinary actions and medical malpractice claims alleged
against the eligible individuals within five (5) years prior to the submission of this FTCA
application (including pending claims), and a brief explanation of risk management
activities the free clinic has taken in response to allegations; and
c. Affirmation signatures by the Chief Executive Officer and Medical Director of the
sponsoring free clinic that all statements and assertions made by the application are
true under penalty of perjury.
Redeeming applications for CY 2012 coverage are due no later than September 16, 2011.
C. SUPPLEMENTAL APPLICATIONS
During the course of the year, sponsoring free clinics may wish to add additional eligible
individuals for FTCA coverage. In order to supplement the free clinic’s list of covered
individuals, a supplemental application must be completed and submitted. This application
form can be found at http://bphc.hrsa.gov/ftca/freeclinics/ and is entitled “Supplemental
Deeming Application.”
A supplemental application form requires:
1) Contact information for the sponsoring free clinic;
2) Location and managers of any new free clinic sites that have been added since the
free clinic’s last FTCA application submission;
3) Confirmation that the sponsoring free clinic and individuals for whom deeming is
sought meet the statutory eligibility criteria;
4) Certification that the free clinic has maintained its credentialing, privileging, and
risk management systems, or a description as to how the system(s) has been
modified;
5) List of all additional individuals (i.e., volunteer health care professionals, board
members, officers, employees and individual contractors) whom the free clinic is
sponsoring for deemed employment status;
6) Requested effective date of FTCA coverage (which may be not less than 30 days
following submission of a complete application); and
7) Affirmation signatures by the Chief Executive Officer and Medical Director of the
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sponsoring free clinic that all statements and assertions made by the application are
true under penalty of perjury.
In addition to a complete supplemental application form, an overall supplemental
application will not be considered complete without the following:
a. A copy of the new QI/QA plan only if it has changed since the most recent original or
redeeming deeming application;
b. Description of any and all disciplinary actions and malpractice claims alleged against any
new sponsored eligible individuals within ten (10) years prior to the submission of this
FTCA application (including pending claims), and a brief explanation of risk management
activities the free clinic has taken in response to allegations; and
c. Affirmation signatures of the Chief Executive Officer and Medical Officer of the
sponsoring free clinic.
III.

GENERAL APPLICATION SUBMISSION INSTRUCTIONS
To streamline FTCA deeming application submission and processing, free clinics should
submit an electronic copy of their deeming application, signature page, and any applicable
attachments to freeclinicsFTCA@hrsa.gov. Each application should be sent in one (1) email.
The email subject line should include the heading “FTCA Deeming Application” and the
free clinic’s FTCA number (FC # XXXX). If the email containing an application does not
indicate the identifying free clinic number, as well as all required information, the application
will not be considered to have been properly submitted. If this is a deeming application for a
new organization, include the words “Original Application” in lieu of the free clinic number.
The application form is to be submitted as an Excel file. Please do not submit a printed and
scanned version of the application form. In order to provide an efficient review, all
individuals should be listed within the application form without hidden fields. Supplemental
applications should only contain new names of individuals requested to be added to a
sponsoring free clinic.
All Initial, Redeeming, and Supplemental applications require an attachment explaining any
and all disciplinary actions and medical malpractice claims alleged against the eligible
individuals applying for deeming. This information is required for the past ten (10) years for
new applicants and five (5) years for renewal applicants. Please do not attach a report from
the National Practitioner Data Bank (NPDB). These reports do not describe the actions taken
by the sponsoring free clinic or the applicant in response to the claims. Additionally, an
NPDB report may disclose information exceeding the time frame requested.
Should review of the application reveal that the required application information supplied by
the sponsoring free clinic is incomplete, the CEO and FTCA Contact listed on the application
will both be contacted, typically via email. The sponsoring free clinic will have ten (10)
business days from the date of notification to submit the requested information to complete
its application. Only one reminder email will be sent after the 10 days have elapsed. If the
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requested information is not received within the given time period, individuals sponsored by
the free clinic may not be deemed by December 31, 2011, and may experience a gap in
coverage.
If the electronic submission process is not feasible, please submit a request for a waiver of
the electronic submission process request to freeclinicsFTCA@hrsa.gov. This waiver request
to file the application by mail must be approved prior to the paper submission.
IV.

CONTACT INFORMATION
For more information on the free clinic deeming application requirements and related
questions, please email freeclinicsFTCA@hrsa.gov or call the BPHC Help Line at
877-974-2742.

James Macrae
Associate Administrator for Primary Care

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APPENDIX A
FREE CLINIC FTCA PROGRAM APPLICATION CHECKLIST
APPLICATION
CHECKLIST

– Free Clinic Health Deeming Application for Volunteer Health Care Professionals,
Board Members, Officers, Employees, and/or Individual Contractors
– Deeming Application – Original or Annual Renewal

ITEMS TO BE ATTACHED:
1) Copy of nonprofit documentation (Initial Application Only)
2) Copy of clinic’s Quality Improvement / Quality Assurance (QI/QA) plan
3) Descriptions of all medical malpractice claims occurring within 10 years prior to the submission
of this deeming application for initial applications or 5 years prior for renewal applications.
4) Signature Page (Appendix B)
APPLICATION NOTES BY SECTION
Section I – Sponsoring Free Clinic
• Send state documentation indicating legal name change if legal name change occurred since
last deeming application.
Section II –Free Clinic Sites
• All free clinic sites must be listed. Each site must be appropriately identified as the
main site or as an additional site.
Section III- Sponsoring Free Clinic Eligibility
• Provide an explanation of any “No” answers in the box below the question.
• Attach IRS nonprofit documentation to application (if Initial Application).
Section IV –Credentialing and Privileging Systems
• Provide an explanation of any “No” answers in the box below the question.
Section V–Risk Management Systems
• Provide an explanation of any “No” answers in the box below the question.
• Attach a copy of the free clinic’s QI/QA plan, including an explanation of the clinic’s risk
management policies. QI/QA plans must be signed and approved by an authorized board
member within three (3) years of the date of the application.
Section VI – Free Clinic Volunteer Health Care Professionals, Board Members, Officers, Employees, and
Individual Contractors
• Provide a list of ALL free clinic volunteer health professionals, board members, officers,
employees, and individual contractors on whose behalf the free clinic is submitting an
application for FTCA deemed status.
• Specify the person’s role in the free clinic for any individual the free clinic is sponsoring
for FTCA deemed status.
• Disclose if the individual has had any past medical malpractice claims or disciplinary
actions for the past 10 years if submitting an original application or for the past 5 years
for renewal applicants.
• Attach an explanation of each medical malpractice claim or disciplinary action including
explanations of the suit, allegation, medical specialty involved, and a description of
whether any action was taken by the clinic to address the claims and prevent further
claims from occurring in the future.

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APPENDIX B
SIGNATURE PAGE
To be considered complete, your application must include a scanned version of this signed page,
emailed to the Bureau of Primary Health Care at freeclinicsFTCA@hrsa.gov.
SECTION VII – SIGNATURES
REQUESTED EFFECTIVE DATE OF FTCA COVERAGE ______________________
(The effective date of FTCA coverage will be no sooner than 30 days following the date of
application submission. Renewal coverage will begin the first day of the calendar year immediately
following the date of application submission.)
We, the undersigned, declare under the penalty of perjury that all statements contained in this
application and any accompanying documents are true and correct, with full knowledge that all
statements made in this application are subject to investigation and that any false or dishonest answer
to any question may be grounds for denial or subsequent revocation of coverage.
CHIEF EXECUTIVE OFFICER
Name (Print or type): ___________________________

Signature

Date

FREE CLINIC MEDICAL DIRECTOR
Name (Print or type): ___________________________

Signature

Date

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