Form 4 Application for Free Clinics to Sponsor Individuals for

OMB Number: 0906-0090

Expiration Date: 05/31/2027

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:

(This application is illustrative and the actual application may appear differently inHRSA’s Electronic Handbooks (EHBs) System)

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0906-0090 and it expires 5/31/2027. This information collection combines three separate ICRs to increase efficiencies, decrease burden on stakeholders, and allow commenters to easily provide feedback where applicable commonalities may impact all three ICRs. The three ICRs are the Application for Health Center Program Recipients for Deemed PHS Employment with Liability Protections Under the FTCA, Application for Deemed Health Center Program Award Recipients and the FTCA Program Deeming Sponsorship Applications for Free Clinics. The Health Center Program and Health Center FTCA Program are administered by HRSA. Health centers submit deeming applications annually to HRSA in the prescribed form and manner in order to obtain deemed PHS employee status, with the associated eligibility for FTCA coverage. Such applications must be approved by HRSA in a Notice of Deeming Action. Deemed health centers must resubmit applications annually meeting all deeming requirements in order to maintain deemed status. The time required to complete this information collection is estimated to average less than 2.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and confidentiality is followed according to law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, MD or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

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:
FTCA Contact First Name: Last Name: E-mail: Phone Number: Fax Number:
*Upload state documentation indicating legal name change if legal name change occurred since last deeming sponsorship application.

Section II. Site Information
Name: Address: Phone Number: Fax Number: E-mail: Site Type: Days/Hours of Operations:

Section II. Site Information

*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.

Note: The sponsoring free clinic must be clearly identified on the submitted documentation. If the documents do not align with the name on the application, you must provide updated documents.

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 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*

*This section is required for all initial deeming and redeeming sponsorship applications. This section is required for supplemental deeming sponsorship applications if the free clinic has changed its credentialing and privileging system since the annual deeming or initial

sponsorship application.

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

Section IV. Credentialing and Privileging Systems*

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 Policy Guide.

[ ] 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. 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.

Section V. Risk Management Systems*

1. The free clinic maintains and implements policies and procedures for the provision of appropriate supervision and back up of clinical staff.

[ ] Yes

[ ] No (If no, then explain)

2. The free clinic maintains a medical record for each patient receiving care from its organization.

[ ] Yes

[ ] No (If no, then explain)

3. The free clinic has policies and procedures that address:

a. Triage [ ] Yes [ ] No

b. Walk-in patients [ ] Yes [ ] No

c. Telephone triage [ ] Yes [ ] No

If No for any of the above, then explain.

4. The free clinic has protocols that identify appropriate treatment and diagnostic procedures based on current standards of care.

[ ] Yes

[ ] No (If no, then explain)

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.

[ ] Yes

[ ] No (If no, then explain)

6. The free clinic periodically reviews patients’ medical records to verify quality,

completeness, and legibility of written entries.

[ ] Yes

[ ] No (If no, then explain)

7. The free clinic has a written, current QI/QA or Risk Management plan that 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).

[ ] Yes

[ ] No (If no, then explain)

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 initial deeming and redeeming sponsorship applications. This attachment is required for supplemental deeming sponsorship applications if the free clinic has changed its QI/QA Plan since the annual redeeming sponsorship application.

Attachment Control (Attachment B. Copy of Clinic’s QI/QA or Risk Management Plan (Maximum 1))

8. The free clinic has regular, periodic meetings to review and assess quality assurance issues.

[ ] 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.)

[ ] No (If no, then explain)

9. The free clinic considers findings from its peer review activities when reviewing and/or

revising its QI/QA plan.

[ ] Yes (If yes, explain what information and process is utilized by the clinic when updating and revising the QI/QA plan.)

[ ] No (If no, then explain)

10. The free clinic utilizes quality assurance findings to modify policies to improve patient

care.

[ ] Yes

[ ] No (If no, then explain)

11. The free clinic’s FTCA-deemed individuals annually participate in risk management continuing education activities.

[ ] Yes (If yes, briefly describe the annual risk management educational activities that are available

to health professionals.)

[ ] No (If no, then explain)

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.

[ ] Yes

[ ] No (If no, then explain)

*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 professionals, Board Members, Officers, Employees, and Individual Contractors*
Add Individual Details Prefix:
First Name: Middle Name: Last Name: Professional Designation:
Contact Information Email Address: Phone Number: Fax Number: Mailing Address:
Roles and Specialty Role(s) in Free Clinic: Specialty: Others: Please enter how many hours on average the volunteer will work per month? Note: **Redeeming applicants should enter the average number of hours per month worked during the previous calendar year.** **Initial and supplemental applicants should enter the estimated or anticipated average number of hours the volunteer plans to work per month for the year that the application is submitted.**

Individual Type (select one): New Applicant Renewal Applicant Service Type Clinical Work activities (Individuals that provide clinical care or participate in the supervision and oversight of clinical care) Non-Clinical Activities (Individuals who conduct purely non-clinical or administrative activities) Both Clinical and Non-Clinical (Individuals who conduct both clinical and non- clinical/administrative activities) Please select the status of the individual from the options below: Employee Individual contractor Officer/Governing Board Member Licensed or Certified Health Professional Volunteer
Credentialing and Privileging Date of Licensure/Certification Expiration Is Licensure/Certification Currently Active? Yes/No. If No, please stop here. Select N/A if this individual is not licensed or certified. Date of Last Credentialing: Date of Last Privileging: [Please remember that all state licensed and/or certified health professionals need to be credentialed and privileged on a recurring basis (for example, every two years). Not mandatory for ‘Board Members’ and ‘Executive’ role.]
Licensure and/or Certification Each sponsored VHP is required to be licensed or certified in accordance with applicable Federal and State laws to perform the services that are requested. [Note: If the answer is No, this volunteer is not eligible for coverage under the Health Center Volunteer Health Professional Program, and should not be included in this application.]

Please upload one of the following: Upload primary source verification of current licensure and/or certification.

Medical Malpractice History For initial or supplemental applicants: Does the sponsored VHP have 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? Include both pending and resolved administrative and civil claims. [ ] Yes [ ] No [N/A]

For redeeming applicants: Does the sponsored VHP have any history of state board disciplinary actions and/or state or federal court (including any FTCA) malpractice claims within five (5) years prior to the submission of this FTCA volunteer health professional deeming application? Include both pending and resolved administrative and civil claims. [ ] Yes [ ] No [N/A] If yes, attach a list of the claims or actions (include probationary actions). For each claim, suit, or action, include the following details and explanation: Area of practice/specialty Date of occurrence Summary of allegations Status or outcome of claim or action 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 FTCA-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). For disciplinary actions, you must include: nature and reason for the disciplinary action, timeframe (where applicable); and documentation from the appropriate professional board that states the individual is in good standing and/or a description of any practice restrictions on the licensee. Do not submit an NPDB report for any individual. Attachment Control (Attachment C. Medical Malpractice Claims and Disciplinary Actions)

Enter Your Comments 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.)

*Notes: 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. Please note that free clinic volunteer health professionals must be licensed and/or certified by state or federal law to perform the services that are requested. Provide a physical address for ALL individuals on whose behalf the free clinic is submitting an application for FTCA deemed status. Physical addresses and phone numbers provided for individuals must be personal mailing addresses that are different than that of the clinic. Specify the role in the free clinic for any individual the free clinic is sponsoring for FTCA deemed status. For each individual sponsored for deeming, disclose past medical malpractice claims or disciplinary actions for the past ten (10) years if submitting an initial or supplemental deeming sponsorship application or for the past five (5) years for redeeming sponsorship applications. List the professional designation (for example: MD, NP, LPN) for all licensed and/or certified individuals for any individual the free clinic is sponsoring for FTCA deemed status. If the individual is not licensed and/or certified and does not have a professional designation, then enter “N/A” for “not applicable.” Attach an explanation of each medical malpractice claim or disciplinary action (to include probationary actions) including explanations of the suit or allegation, medical specialty involved, and a brief statement of whether the clinic implemented appropriate risk management actions as needed in response to allegations to reduce the risk of future malpractice and future such claims. Documentation related to a disciplinary action must include: nature and reason for the disciplinary action; timeframe (where applicable); documentation from the appropriate professional board that states the individual is in good standing and/or a description of any practice restrictions on the licensee. Do NOT submit an NPDB report for any individual.

Section VII. Patient Visit Data*
1. Total number of Free Clinics FTCA Program deemed individuals, (including health professionals, officers, board members, employees, or contractors, in the recently closed calendar year.
2. Total number of Free Clinics FTCA Program deemed health professionals (including but not limited to clinical providers, such as doctors, nurses, medical assistants). Note: This number should not exceed the number reported within Section VII, item 1

above, in the recently closed calendar year. This number should include all individuals providing clinical services.
3. Total number of patient visits conducted by Free Clinics FTCA Program deemed providers: not to exceed the number reported within Section VII, item 1 above, in the recently closed calendar year.
*Only required for the annual redeeming sponsorship application.

Section VIII. Attachments

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 Health Center Program Support Phone: 1-877-464-4772, Option 1 8:00 a.m. to 5:30 p.m. ET, Monday through Friday (except Federal holidays) or web form: https://hrsa.force.com/support/s/.

[ ] 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.