Free Clinics FTCA Program Application

ICR 201807-0915-002

OMB: 0915-0293

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2018-07-30
Justification for No Material/Nonsubstantive Change
2018-07-27
Supplementary Document
2017-10-25
Supporting Statement A
2017-10-25
IC Document Collections
IC ID
Document
Title
Status
6548 Modified
ICR Details
0915-0293 201807-0915-002
Historical Active 201709-0915-002
HHS/HSA
Free Clinics FTCA Program Application
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 07/31/2018
Retrieve Notice of Action (NOA) 07/27/2018
  Inventory as of this Action Requested Previously Approved
11/30/2020 11/30/2020 11/30/2020
684 0 684
1,368 0 1,368
0 0 0

Deemed status for FTCA medical malpractice coverage requires HRSA approval of an application for deeming of certain eligible individuals from a sponsoring Free Clinic. The FTCA Program Deeming Application for Free Clinics is an electronic application submitted to HRSA through the Electronic Handbooks as part of the process of deeming qualified health care professionals, board members, officers, and individual contractors.

US Code: 42 USC 233(o) Name of Law: Health Insurance Portability and Accountability Act of 1996
  
None

Not associated with rulemaking

  82 FR 28667 06/23/2017
82 FR 46511 10/05/2017
No

1
IC Title Form No. Form Name
Free Clinics FTCA Program Application 1 CY 2019 Free Clinic Program application CLEAN.docx

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 684 684 0 0 0 0
Annual Time Burden (Hours) 1,368 1,368 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$126,117
No
    Yes
    Yes
No
No
No
Uncollected
Elyana Bowman 301 443-3983 enadjem@hrsa.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/27/2018


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