OMB No. 0915-0293
Expires: 1/31/2024
FREE CLINICS FTCA PROGRAM APPLICATION
The following tables provide the information that will be collected in the initial, redeeming, and supplemental deeming sponsorship applications through the EHBs:
Section I. Contact Information* |
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Executive Director
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Medical Director
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Risk Management Coordinator
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FTCA Contact
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*Upload state documentation indicating legal name change if legal name change occurred since last deeming sponsorship application. |
Section II. Site Information |
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*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 |
1. (Required for initial and redeeming applicants). The sponsoring free clinic is a registered nonprofit organization. Please attach nonprofit documentation.)
Attachment Control (Attachment A. Non-Profit Documentation (Maximum 5)) |
[ ] Yes |
2. The sponsoring free clinic and its sponsored individuals comply with the definitions relative to covered individuals (employees, contractors, volunteer health professionals, and board member and officers) as set forth in section III, “Covered Individuals”, of the Free Clinics FTCA Program Policy Guide. |
[ ] Yes |
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). |
[ ] Yes |
4. The free clinic does not impose charges on patients either based on service provided or the ability to pay. (The free clinic may accept only volunteer donations from patients and other third parties.) |
[ ] Yes |
5. The free clinic is licensed or certified in accordance with applicable law regarding the provision of health services. |
[ ] Yes |
[ ] No (If no, then explain) |
6. The free clinic and/or individual health care professional provides each patient with a written notification explaining that the legal liability of the deemed individual is limited pursuant to section 224(o) of the Public Health Service Act, 42 U.S.C. 233(o). |
[ ] Yes |
Section IV. Credentialing and Privileging Systems* |
1. The free clinic verifies licensure, certification, and/or registration of each licensed and/or certified individual according to the instructions in the Free Clinics FTCA Program Policy Guide. (Please remember all volunteer health professionals must be licensed or certified to be eligible for deeming.) |
[ ] Yes |
2. The free clinic has a copy of the current license, certification, and/or registration on file at the free clinic for each licensed and/or certified individual. (Please remember all volunteer health professionals must be licensed or certified to be eligible for deeming.) |
[ ] Yes |
3. If the free clinic contracts with a Credentialing Verification Organization (CVO) for CVO services, there is a written contractual agreement stating the specifics of these services. |
[ ] Yes |
[ ] N/A |
4. The free clinic utilizes peer review activities when it privileges each licensed and/or certified individual according to the instructions in the Free Clinics FTCA Program |
[ ] Yes |
This section is required for all initial deeming and redeeming deemingapplications if the free clinic has changed its credentialing and privileging system since the annual sponsorship applications. This section is required for supplemental deeming sponsorship or initial application. sponsorship |
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. Note: do NOT submit a copy of the NPDB report for any individual to HRSA. |
[ ] Yes |
7. Name and contact information of the person and organization conducting credentialing/privileging. |
Enter the name and contact information in the Comments section of this question. |
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Section V. Risk Management Systems* |
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1. The free clinic maintains and implements policies and procedures for the provision of appropriate supervision and back-up of clinical staff. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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2. The free clinic maintains a medical record for each patient receiving care from its organization. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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3. The free clinic has policies and procedures that address: |
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a. Triage [ ] Yes [ ] No |
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b. Walk-in patients [ ] Yes [ ] No |
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c. Telephone triage [ ] Yes [ ] No |
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If No for any of the above, then explain. |
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4. The free clinic has protocols that identify appropriate treatment and diagnostic procedures based on current standards of care. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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5. The free clinic has a tracking system for patients who miss appointments or require follow-up of referrals, hospitalization, diagnostics (for example, x-rays), or laboratory results. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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6. The free clinic periodically reviews patients’ medical records to verify quality, completeness, and legibility of written entries. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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7. The free clinic has a written, current QI/QA or Risk Management plan othat clearly addresses the clinic’s credentialing and privileging process and has been signed by a board authorized representative on a recurring basis (for example, every three (3) years) (please attach a copy of the plan with documentation of board approval, including date of approval). |
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[ ] Yes |
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[ ] No (If no, then explain) |
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Attach the free clinic’s QI/QA or Risk Management Plan that has been approved, signed, and dated by a board authorized representative on a recurring basis (for example, every three (3) years):
This attachment is required for supplemental deeming application. sponsorship Plan since the annual redeeming applications if the free clinic has changed its QI/QAsponsorship
Attachment Control (Attachment B. Copy of Clinic’s QI/QA or Risk Management Plan (Maximum 1)) |
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8. The free clinic has regular, periodic meetings to review and assess quality assurance issues. |
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[ ] Yes (If yes, briefly describe the structure (e.g., frequency of meetings, individuals required to attend, etc.) of the committee that meets periodically to review and assess quality assurance issues.) |
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[ ] No (If no, then explain) |
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9. The free clinic considers findings from its peer review activities when reviewing and/or revising its QI/QA plan. |
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[ ] Yes (If yes, explain what information and process is utilized by the clinic when updating and revising the QI/QA plan.) |
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[ ] No (If no, then explain) |
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10. The free clinic utilizes quality assurance findings to modify policies to improve patient care. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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11. The free clinic’s FTCA-deemed individuals annually participate in risk management continuing education activities. |
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[ ] Yes (If yes, briefly describe the annual risk management educational activities that are available to health professionals.) |
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[ ] No (If no, then explain) |
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12. The free clinic has assured that each individual sponsored for FTCA deemed status has a copy of the Free Clinics FTCA Program Policy Guide, and that his/her questions regarding FTCA medical malpractice coverage have been addressed. |
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[ ] Yes |
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[ ] No (If no, then explain) |
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*Required for initial deeming and redeeming sponsorship applications. Required for supplemental deeming sponsorship applications if the free clinic has changed its QI/QA Plan since the annual redeeming sponsorship application. |
Section VI. Free Clinic Volunteer Health Care Professionals, Board Members, Officers, Employees, and Individual Contractors* |
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Add Individual Details
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Contact Information
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Is this volunteer a COVID-19 vaccination volunteer who will be volunteering solely to administer COVID-19 vaccinations?
[] Yes [] No
Roles and Specialty
[Upload a signed volunteer agreement for each individually named volunteer that clearly states that the sponsored health professional is a volunteer of the health center, outlines the terms and conditions of the services that the volunteer will provide, acknowledges that the health professional will not receive any compensation including reimbursement from any third party services.], and documents each off-site program or event where the health professional will provide payor
Note: For volunteers that are solely administering CID-19 vaccines, the volunteer agreement should clearly include that information and should also any other state or federal requirements that must be met for the individual to volunteer as a COVID-19 vaccinator.OV
Please estimate, how many hours on average will the volunteer work per month?
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Individual Type (select one):
Service Type
Please select the status of the individual from the options below:
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Credentialing and Privileging
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Licensure and/or Certification
Each sponsored .]application this Program, and should not be included in the Health Center Volunteer Health Professional this volunteer is not eligible for coverage under answer is No, If the is required to be licensed or certified in accordance with applicable Federal and State laws to perform the services that are requested. [Note: VHP
Or
For to administer COVID-19 vaccinations under a special grant of authority due to the ongoing COVID-19 pandemic.VHP that are solely administering COVID-19 Vaccines, the individual is operating under a state or federal legislation, declaration, or exemption that permits the VHPs
[No [ ]Yes ]
Please upload one of the following:
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Medical Malpractice History
[No [ ]Yes ] [N/A]
[No [N/A] [ ]Yes ]
If yes, attachactions a list of the claims or (include probationary actions). For each claim, suit, or action, include the following details and explanation:
Summary of how the sponsoring health center and sponsored individual volunteer have/will implement steps to mitigate the risk of such claims or actions in the future (if -related, only submit a summary if the case is closed. If the case has not been resolved, indicate this and do not include the summary).FTCA
For disciplinary actions, you must include:
Do not submit an report for any individual.NPDB
Attachment Control (ActionsAttachment C. Medical Malpractice Claims and Disciplinary )
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Enter Your Comments
(Comments and an attachment with an explanation of each medical malpractice claim or disciplinary action are required for individuals where medical malpractice claims or disciplinary actions are indicated. Do NOT submit an NPDB report for any individual.) |
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*Notes:
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Section VII. Patient Visit Data* |
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1. Total number of Free Clinics FTCA Program deemed individuals, in the recently closed calendar year: |
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2. Total number of Free Clinics FTCA Program deemed providers, in the recently closed calendar year: |
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3. Total number of patient visits conducted by Free Clinics FTCA Program deemed providers, in the recently closed calendar year: |
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*Only required for the annual redeeming sponsorship application. |
Section VIII. Attachments |
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Attachment D. Other supporting Documentation (Maximum 5) |
Please attach any other supporting documentation. |
Section IX. Remarks |
Are you interested in receiving FREE access to the Clinical Risk Management website? Registration provides you with continuing medical education training opportunities, sample policies and tools, e-newsletters covering current topics in patient safety and risk management, and more!
*You may opt out of receiving email notifications at any time by contacting: freeclinicsftca@hrsa.gov. |
[ ] Yes [ ] No |
Section X. Signatures |
Certification and Signature |
I, (Executive Director)*, certify that this sponsoring free clinic meets the definition of a free clinic found in Section III of the HRSA/BPHC Free Clinics FTCA Program Policy Guide 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. |
Public Burden Statement: Congress enacted FTCA medical malpractice protection for volunteer Free Clinic health professionals through Section 194 of HIPAA of 1996 (Public Law 104-191) by amending Section 224 of the Public Health Service (PHS) Act (42 U.S.C. 233). However, Congress appropriated funds for the Free Clinic FTCA Program for the first time in late January 2004. In 2010, the Patient Protection and Affordable Care Act (Affordable Care Act) (Public Law 111-148) expanded eligible individuals to include employees, officers, board members, and contractors, in addition to volunteers. The application submissions provide BPHC with the information required to determine whether an individual meets the requirements for deemed PHS employment for purposes of providing liability protections under section 224(q) of the PHS Act. The OMB control number for this information collection is 0915-0293 and it is valid through 1/31/2024. This information collection is required to verify that the free clinic meets the criteria to sponsor a deeming application and that the individual being sponsored is eligible to be deemed as a PHS employee with associated FTCA coverage for their activities within the scope of deemed employment on behalf of the health center. Public reporting burden for this collection of information is estimated to average 2 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Calendar Year 2019 Federal Tort Claims Act (FTCA) Deeming Application for Free Clinics |
Subject | Calendar Year 2019 Federal Tort Claims Act (FTCA) Deeming Application for Free Clinics |
Author | HRSA |
File Modified | 0000-00-00 |
File Created | 2021-05-19 |