Form 0285 ftca form 0285 ftca form 0285 ftca form

OMB No. 0915-0285

Expiration Date:

BPHC Policy Information Notice 99-08

APPLICATION FOR

For Medical/Dental Professional Liability Protection

FEDERAL TORT CLAIMS ACT

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour 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 10-33, Rockville, Maryland, 20857.

SECTION I - APPLICANT INFORMATION

GRANTEE NAME:

DBA Name (if appropriate):

UDS #:

Community Health Sub-Grantee

Migrant Health Co-Applicant

Health Care for the Homeless Sub-Recipient

Health Care for Residents of Public Housing

School Health Programs

ADDRESS:

E-mail address:

TELEPHONE #: FAX #:

EXECUTIVE DIRECTOR: Telephone Number:

MEDICAL DIRECTOR: Telephone Number:

SECTION II - CREDENTIALING SYSTEM
Answer YES or NO to the following questions by marking the appropriate box. NO answers require explanation on a separate sheet		YES	NO
Is professional educational background and postgraduate training verified?
Is primary source verification of licensure, certification, and/or registration performed?
Is board certification verified for physicians?
Is a copy of current licensure, certification, and/or registration on file?
Is a copy of hospital privileges on file, if applicable?
Are professional references obtained and reviewed?
Is a history of previous malpractice liability claims and adverse actions reviewed?
Are health care practitioners required to submit a personal statement or other evidence of health fitness at the time of credentialing?
Is the Health Center involved in peer review activities?
If Yes, is it a formal process? (Formal means written procedures on peer review activities are formally adopted by the governing body and provide for adequate notice and opportunity for a fair hearing on any adverse recommendations.)
Is the National Practitioner Databank queried in credentialing your health care practitioners?

SECTION III – RISK MANAGEMENT POLICIES/PROCEDURES
Answer Yes or NO to the following questions by marking the appropriate box. NO answers require explanation on a separate sheet.	YES		NO
Are there policies/procedures on the appropriate supervision and back-up of clinical staff?
Is a medical record maintained for every patient receiving care at the Health Center?
Are there policies/procedures that address triage, walk-in patients, and telephone triage?
Are there clinical protocols that define appropriate treatment and diagnostic procedures for selected medical conditions?
Is there a tracking system for patients who require follow-up of specialty referrals, hospitalization, x-ray, and lab results?
Are medical records periodically reviewed to determine quality, completeness, and legibility?
Is there a written Quality Assurance Plan approved by the governing body? If yes, attach a copy of the most recent Quality Assurance Plan with the approval date noted.
Are quality assurance findings used to modify policies/procedures in order to improve quality of care?

SECTION IV – SERVICES TO NON-HEALTH CENTER PATIENTS

Are services provided to non Health Center patients? If yes, check all that apply based on the examples listed in the Federal Register Notice (Vol. 60, pages 49417-18) issued September 25, 1995.

COMMUNITY-WIDE INTERVENTIONS

School-based clinics

School-linked clinics

Health Fairs

Immunization Campaign

Outreach

HOSPITAL-RELATED ACTIVITIES

Hospital call as required for privileges

Emergency Room coverage as required for privileges

COVERAGE-RELATED ACTIVITIES

Cross-coverage with community providers

If the services do not appear to fall under the examples cited, then the Health Center should submit a separate request to the Director, BPHC, for a determination of the applicability of FTCA coverage as outlined in Section V of this BPHC PIN.

SECTION V - SIGNATURES

Requested Effective Date of FTCA Coverage:

(FOR ORIGINAL DEEMING ONLY)

EXECUTIVE DIRECTOR NAME:

(Print or Type)

SIGNATURE: DATE:

MEDICAL DIRECTOR NAME:

(Print or Type)

SIGNATURE: DATE: