Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

0293 Compare Free Clinic Deeming Application OLD v. NEW October 2020

Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

OMB: 0915-0293

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APPENDIX A

FREE CLINICS FTCA PROGRAM APPLICATION



The following tables provide the information that will be collected in the initial, redeeming, and supplemental deeming sponsorshipsapplication through the :sEHB


Section I. Contact Information*

Executive Director

  • First Name:

  • Last Name:

  • E-mail:

  • Phone Number:

  • Fax Number:


Medical Director

  • First Name:

  • Last Name:

  • E-mail:

  • Phone Number:

  • Fax Number:


Risk Management Coordinator

  • First Name:

  • Last Name:

  • E-mail:

  • Phone Number:

  • Fax Number:






Public Burden Statement:  . paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 
















.Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free Clinics FTCA Program Policy HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h



















. Program Policy Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free Clinics FTCA HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h 









Free Clinics FTCA Program HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h 

 HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h

[ ] Yes




5. The free clinic annually reviews any history of prior and current medical malpractice claims for each individual for whom deeming is sought.

[ ] Yes


6. A National Practitioner Data Bank (NPDB) query is obtained and evaluated on a recurring basis (for example, every two years) for each licensed and/or certified individual according to the instructions in the.Free Clinics FTCA Program Policy Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h






























































,Free Clinics FTCA Program Policy Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h























































































freeclinicsftca@hrsa.gov. HYPERLINK "mailto:freeclinicsftca@hrsa.gov" \h







 HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h and that the information in this application and the related attachments is complete and accurate.

*The application must be signed by the Executive Director, as indicated Section I. Contact Information.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCalendar Year 2019 Federal Tort Claims Act (FTCA) Deeming Application for Free Clinics
SubjectCalendar Year 2019 Federal Tort Claims Act (FTCA) Deeming Application for Free Clinics
AuthorHRSA
File Modified0000-00-00
File Created2021-01-13

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