3 Emergency Deeming Sponsorship Application

Applications for Deemed Public Health Service Employment with Liability Protections Under the FTCA for Health Centers, Deemed Health Center Volunteers, and Free Clinic Sponsored Individuals

Health Center VHP Emergency Deeming Application Tool

OMB: 0906-0090

Document [pdf]
Download: pdf | pdf
Volunteer Health Professionals (VHP) Emergency Deeming Sponsorship Application
(Note: The application form below is only illustrative. HRSA may specify
different requirements for the VHP Emergency Deeming Sponsorship
Application in HRSA’s Electronic Handbooks (EHBs) System.)
Department of Health and Human Services
Health Resources and Services Administration
OMB#

Award
Recipient
Name

Grant
Number

Contact Information
CONTACT INFORMATION (Include an honorific (e.g., Ms.,
Mrs., Mr., Dr., etc.) before the name) All fields marked with an
* are required.
EXECUTIVE DIRECTOR (Must electronically sign and certify
the volunteer health professional sponsorship application prior
to submission)
* Name:
* Email:
* Direct Phone: Fax:
Section I. Sponsoring Health Center Acknowledgements of Deemed Status Requirements
1. The sponsoring health center acknowledges its understanding that, under section 224(q)(3)(B)
of the Public Health Service (PHS) Act, only a health center entity receiving funds under
section 330 of the PHS Act (the Health Center Program) and deemed as a PHS employee
under the Federally Supported Health Centers Assistance Acts (FSHCAA) of 1992 (Pub. L.
102-501) and 1995 (Pub. L. 104-73), as amended, may sponsor a volunteer health professional
(VHP) to become a deemed PHS employee for purposes of liability protections for those
individual VHPs under section 224(q) of the PHS Act.
[ ] Yes [ ] No
2. The sponsoring health center also acknowledges its understanding that, if its entity
FTCA deeming or redeeming application for the applicable calendar year is not
approved, its sponsored volunteers will become automatically ineligible for FTCA
coverage as deemed PHS employees for that calendar year under section 224(q) of the
PHS Act.
[ ] Yes [ ] No
3. Further, the health center acknowledges its understanding that, by signing this VHP
application, the materials submitted as part of its initial entity FTCA deeming or redeeming
application and the entity’s Notice of Deeming Action will be utilized by HRSA in
determining whether the entity is eligible to sponsor health center volunteers for deemed
PHS employment. [ ] Yes [ ] No

Section II. Volunteer Health Professional: Acknowledgment of Required Performance
Conditions (Responses Required)
For each of the individual VHP listed in Section III below, the sponsoring health center
acknowledges its understanding that, for a volunteer to be considered a VHP, the following
requirements must be met:
1. The services provided by the VHP occur at the sponsoring health center’s facilities
(i.e., at its approved service sites) or through offsite programs or events carried out by the
sponsoring health center (section 224(q)(2)(A)).
[ ] Yes
2. The VHP does not receive any compensation for the service from the individual, the sponsoring
health center, or any third-party payer (including reimbursement under any insurance policy,
health plan, or federal or state health benefits program); except that the VHP may receive
repayment from the sponsoring health center for reasonable expenses incurred by the VHP in the
provision of the service to the individual, which may include travel expenses to or from the site of
services (section 224(q)(2)(C)).
[ ] Yes
3. Before the service is provided, the VHP or the sponsoring deemed health center posts a clear and
conspicuous notice at the site where the service is provided of the extent to which the legal liability of
the health care practitioner is limited pursuant to the Public Health Service Act (section
224(q)(2)(D)).
[ ] Yes
4. At the time the service(s) is provided, the VHP(s) is licensed or certified in accordance with
applicable federal and state laws regarding the provision of the service(s) (section 224(q)(2)(E)).
[ ] Yes
5. The sponsoring health center maintains all relevant documentation certifying that the
volunteer meets the requirements to be considered a VHP (section 224(q)(2)(F)).
[ ] Yes
The sponsoring health center acknowledges its understanding that for each VHP the following is
required:
6. Before the service is provided, the sponsoring health center must credential and privilege the
VHP(s) in accordance with all current Health Center Program and FTCA Program credentialing and
privileging requirements and maintain this information in a file for each VHP (section 224(q)(3)).
[ ] Yes
7. The health center attests that it has performed a background check in accordance with
state/jurisdiction law for health care practitioners (where required)
[ ] Yes

Section III. Volunteers Sponsored for Deeming
Please specify the HRSA-approved declared emergency or
other emergency situation (Please note: Declared
emergencies that HRSA has not indicated qualify for the
submission of this type of VHP application will not be
approved.)
Comment Box:

For each Volunteer Health Professional sponsored for
deeming, provide the following information.
(Note 1: Do NOT include on this listing individuals who are not
volunteer health professionals, such as employees, contractors,
governing board members and officers.)
(Note 2: Do NOT include on this listing individuals who are trainees
(i.e., students, interns, or residents) conducting duties as part of a
residency program. These individuals are not eligible for deemed
PHS employment through the VHP Program.)

Add Individual Details*
• Prefix:
• First Name:
• Middle Name:
• Last Name:
• Professional Designation (e.g., MD, RN, etc.):
Contact Information
• Work Email Address:
• Work Phone Number:
• Work Fax Number:
• Work Mailing Address:
• Personal Email Address:
• Personal Phone Number:
• Personal Fax Number (if any):
• Personal Mailing Address:

Section III. Volunteers Sponsored for Deeming
Volunteer Health Professional Agreement and Education
I attest that the health center has a volunteer agreement for each
individually named volunteer that clearly states:
a) that the sponsored health professional is a volunteer of the
health center,
b) the terms and conditions of the services that the volunteer will
provide,
c) that the health professional will not receive any compensation
including reimbursement from any third-party payor.
[ ] Yes

[ ] No

I attest that my health center has provided each individually named
volunteer health professional information explaining the limits of
liability protections under section 224(q), including documentation of
each off-site program or event where the health professional will
provide services on behalf of the health center.
[ ] Yes

[ ] No

Credentialing and Privileging

I attest that each individually named volunteer health professional has
been credentialed and privileged by the health center in accordance
with all applicable Health Center Program and FTCA Program
credentialing and privileging requirements. (Each sponsored VHP
must be credentialed and privileged by the health center in
accordance with the Health Center Program Compliance Manual,
Chapter 5 or, when applicable, PAL 2017-07.) All volunteers must be
credentialed at least every two years.
Licensure and/or Certification
I attest that the sponsored VHP is required to be licensed or
certified in accordance with applicable Federal and State laws to
perform the services that are requested and the health center, when
possible, has verified all appliable license information via primary
source verification.
[ ] Yes [ ] No

Section III. Volunteers Sponsored for Deeming
Medical Malpractice History
• I attest that the health center has reviewed the medical
malpractice claims history for the sponsored VHP and any
history of state board disciplinary actions and/or state or
federal court (including any FTCA) malpractice claims
within ten (10) years prior to the submission of this FTCA
volunteer health professional deeming application? This
review included both pending and resolved administrative
and civil claims. I attest that, based on this review, the
health center has determined that the sponsored VHP does
not present an unacceptable risk of medical malpractice
claims or lawsuits.
[ ] Yes
[ ] No
*Notes:
• Within the EHBs, the sponsoring health center is required to
submit the information outlined above for each individual
volunteer for whom it is seeking FTCA coverage.
• The sponsoring health center must provide both work and
personal contact information for each health center VHP the
health center is sponsoring for FTCA deemed status.
Section IV. Signatures
Certification and Signature
I,
(Authorized Health Center Representative)*, have the authority to act on behalf of the health
center with respect to this application and certify that, to the best of my knowledge and belief, (1) this sponsoring
health center meets the statutory eligibility criteria for deemed status/FTCA coverage, as reflected in its current
calendar year deeming application; (2) this sponsoring health center has maintained its credentialing, privileging,
and risk management systems in accordance with Health Center Program and Health Center FTCA Program
requirements; and (3) the information in this application and the related attachments is complete and accurate. I
understand that by printing my name I am signing the application under penalty of perjury.
*The application must be signed by Health Center Representative, as indicated in Section I. Contact
Information.


File Typeapplication/pdf
File TitleInstructions for Completing Federal Tort Claims Act Volunteer Health Professionals Emergency Deeming Sponsorship Applications
SubjectProgram Assistance Letter, Calendar Year 2024, Volunteer Health Professionals, Federal Tort Claims Act (FTCA), Sponsorship Appli
AuthorHRSA
File Modified2024-04-15
File Created2024-04-05

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