Form 0293 Deeming Application

BPHC Program Information Notice 2004-24

Federal Tort Claims Act Coverage of Free Clinic Volunteer Health Care
Professionals
I. PURPOSE
This Program Information Notice (PIN) supersedes PIN 2004-24 and provides detailed
information regarding the implementation of the Free Clinic Federal Tort Claims Act
(FTCA) Medical Malpractice Program (the Program) as described in Section 194 of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA). This PIN provides
information on:
1) Who is covered;
2)
What services are covered;
3)
What are the Program requirements;
4)
How are claims processed;
5)
What is the application process; and
6)
Other types of recommended insurance.
II. OVERVIEW
Congress enacted FTCA medical malpractice protection for volunteer free clinic health
care professionals through Section 194 of HIPAA (Public Law 104-191) by amending
Section 224 of the Public Health Service (PHS) Act (42 U.S.C. § 233). If a volunteer
health care professional meets all the requirements of the Program, the related free clinic
can sponsor him/her to be a “deemed” PHS employee for the purpose of FTCA medical
malpractice coverage. FTCA deemed status provides the volunteer licensed or certified
health care professional with immunity from medical malpractice lawsuits resulting from
his/her subsequent performance of medical, surgical, dental or related functions within
the scope of his/her work at the free clinic. Claimants alleging acts of medical
malpractice by the deemed volunteer health care professional must file their claims
against the United States according to FTCA requirements. The payment of claims will
be subject to Congressional appropriations for the program. Free clinics must submit an
annual FTCA deeming application on behalf of their volunteer free clinic health care
professionals to the Department of Health and Human Services’ (HHS) Health Resources
and Services Administration, Bureau of Primary Health Care (HRSA, BPHC) that
administers the Program.
III. WHO IS COVERED?
HHS will deem a volunteer free clinic health care professional to be a PHS employee for
the purposes of FTCA coverage for medical malpractice claims if the free clinic and
health care professional meet certain requirements.
A free clinic is a health care facility operated by a non-profit1 private entity that:
1) In providing health care, does not accept reimbursement from any third-party
payor (including reimbursement from any insurance policy, health plan, or
Federal or State health benefits program that is individually determined);

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The IRS under section 501(c) (3) of the Internal Revenue Code should have conferred the non-profit status of the
health care facility operating the free clinic.

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2) In providing health care, does not impose charges on patients to whom service is
provided OR imposes charges on patients according to their ability to pay;2
3) May accept patients’ voluntary donations for health care service provision; and
4) Is licensed or certified to provide health services in accordance with applicable
law.3
A volunteer free clinic health professional:
1) Provides services to patients at a free clinic or through offsite programs or events
carried out by a free clinic;
2) Is sponsored by a free clinic;
3) Provides a qualifying health service (i.e., any medical assistance required or
authorized to be provided under Title XIX of the Social Security Act (42 U.S.C. §
1396 et. seq.)) without regard to whether the medical assistance is included in the
plan submitted by the State in which the health care practitioner provides the
service;
4) Does not receive compensation for provided services from patients directly or
from any third-party payor;
5) May receive repayment from a free clinic for reasonable expenses incurred in
service provision to patients;
6) Is licensed or certified to provide health care services3 at the time of service
provision in accordance with applicable law; and
7) Provides patients with written notification before service provision of the extent
to which his/her legal liability is limited pursuant to the PHS Act if his/her
associated free clinic has not already provided such notification (see Section
V(B)).
An example of a FTCA covered offsite program or event carried out by a free clinic is a
health fair sponsored by the free clinic. If a free clinic is unsure whether an offsite
program or event is covered by FTCA, the free clinic may apply to the HRSA Associate
Administrator for Primary Care (through the Free Clinic FTCA Program) for a
determination of coverage. The request must sufficiently detail:
1) What service(s) is being provided;
2) Who is providing the service;
3) Where the service is being provided; and
4) Why the free clinic volunteer(s) is providing the service.

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If the free clinic imposes charges based on a patient’s ability to pay, this will negate the FTCA coverage of the
volunteer(s) for the specific services for which the clinic received payment.
3
A licensed or certified health care practitioner is an individual required to be licensed, registered, or certified by the
State, Commonwealth or territory in which a free clinic is located. These individuals include, but are not limited to:
physicians, dentists, registered nurses, and others required to be licensed, registered, or certified (e.g., laboratory
technicians, social workers, medical assistants, licensed practical nurses, dental hygienists, and nutritionists). The
definition will vary dependent upon legal jurisdiction.

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IV. WHAT SERVICES ARE COVERED?
FTCA deemed volunteer free clinic health care professionals are eligible for medical
malpractice coverage for health care service acts or omissions that:
1) Arise from services required or authorized to be provided under Title XIX of the
Social Security Act (i.e., Medicaid Program) regardless of whether the service is
included in the State Medicaid plan in effect for the volunteer free clinic health
care professional’s work site(s);
2) Arise from the provision of medical, surgical, dental or related services at a free
clinic site or through offsite programs or events carried out by the free clinic; and
3) Occur on or after the effective date that the HHS Secretary approves the FTCA
deeming application submitted by the free clinic on behalf of its volunteer free
clinic health care professionals.
V. WHAT ARE THE PROGRAM REQUIREMENTS?
Free clinics and their FTCA deemed volunteer health care professionals must satisfy
various program requirements. The requirements related to credentialing and privileging
systems and patient notification of limited liability are described in detail in this PIN. The
Program applications outline other Program requirements related to risk management
systems and periodic review of medical malpractice claims history (see Appendices A &
B).
A. Credentialing and Privileging
Credentialing and Privileging Definitions
HHS will deem a volunteer free clinic health care professional to be a PHS
employee for purposes of FTCA coverage for medical malpractice claims if
specific credentialing and privileging requirements are met. For the purposes of
the Program:
1) Credentialing is the process of assessing and confirming the qualifications
(e.g., licensure, certification, and/or registration) of a licensed or certified
health care practitioner; and
2) Privileging is the process of authorizing the specific scope and content of
patient care services of a licensed or certified health care practitioner. This
is performed in conjunction with an evaluation of the health care
practitioner’s clinical qualifications and/or performance.
Free clinics can satisfy many of the credentialing and privileging requirements by
utilizing primary and secondary source verification. For the purposes of the
Program:
1) Primary source verification is verification of an individual health care
practitioner’s reported qualification by the original source or an
approved agent. Examples of primary source verification of credentials
include direct correspondence, telephone verification, or internet
verification from the original qualification source or reports from
credentials verification organizations (CVOs). For example, the Education
Commission for Foreign Medical Graduates (ECFMG), the American
Board of Medical Specialties (ABMS), the American Osteopathic

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Association (AOA) Physician Database, or the American Medical
Association (AMA) Masterfile can be used for primary source verification
of health care practitioners’ education and training. Hospitals also can
serve as CVOs to conduct primary source verification for free clinics.
When using a CVO for primary source verification, the free clinic is
relieved from the process of gathering the information, but it is not
relieved from the responsibility of having complete and accurate
information. Therefore, a free clinic that bases its decisions in part on
information obtained from a CVO should achieve a level of confidence in
the information provided by the CVO (For more information, consult
Credentialing and Granting of Privileges, 2004 Comprehensive
Accreditation Manual for Ambulatory Care, Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), pg. HR-10).
2) Secondary source verification is verification by methods not considered
acceptable for primary source verification. Examples of secondary source
verification of credentials include viewing the original credential, a
notarized copy of the credential, or a copy of the credential (when the
copy was made from an original by an authorized participant of the
organization’s credentialing process).
Only volunteer health care professionals who are currently licensed or certified
are eligible for FTCA deemed status (see Section III). Licensed or certified health
care practitioners can be divided into two categories:
1) A licensed independent practitioner (LIP) is a physician, dentist,
nurse practitioner, nurse midwife, or any other individual permitted
by law and the organization to provide care and services without
direction or supervision, within the scope of the individual
practitioner’s license and consistent with individually granted
clinical privileges; and
2) Another licensed or certified health care practitioner is an
individual who is licensed, registered, or certified but is not
permitted by law to provide patient care services without direction
or supervision. Examples include, but are not limited to, laboratory
technicians, social workers, medical assistants, licensed practical
nurses, and dental hygienists.
Credentialing and Privileging Requirements
The free clinic must determine whether each volunteer health care professional
meets the definition of a LIP or other licensed or certified health care practitioner
based on State law and the free clinic’s policies. Further, the free clinic must
assure that these licensed or certified health care practitioners are credentialed and
privileged. Credentialing and privileging requirements differ depending on
whether the volunteer health care professional is a LIP or other licensed or
certified health care practitioner.

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Initial Credentialing of LIPs
The initial credentialing of LIPs should include:
1) Primary source verification of:
a) Current licensure;
b) Relevant education, training, or experience; and
c) Health fitness or the ability to perform the requested
privileges (This can be determined by a statement from the
individual that is confirmed either by the director of a
training program, chief of staff/service of a hospital where
the individual has privileges, or a licensed physician
designated by the organization);
2) Secondary source verification of:
a) Identification (via a government issued picture id);
b) Drug Enforcement Administration registration, as applicable;
c) Hospital admitting privileges, as applicable;
d) Immunization and TB skin test result status; and
e) Life support training, as applicable; and
3) Querying the National Practitioner Data Bank (NPDB), as
applicable (If the free clinic is ineligible to query the NPDB, it
should have the LIP provide the results of a self-query).
The free clinic should complete the credentialing process for the LIP prior to the
practitioner providing patient care services at the free clinic.
Initial Privileging of LIPs
The initial privileging of a LIP involves the assessment of his/her current
competence in the specific scope or content of patient care services he/she is to
provide at the free clinic. The free clinic should assure that the specific
assessment procedures utilized are appropriate for the LIP’s specialty, breadth of
clinical services to be provided to patients, and accessibility to ancillary and
tertiary medical practitioners. A free clinic could assess a LIP’s competence by
any combination of:
1) Primary source verification of a course of study from a recognized
and certifying educational institution showing that the LIP met or
passed a level of training required to perform a defined procedure
or management protocol;
2) Documentation of first hand, one-on-one review of the LIP’s
competence in particular procedures or management protocols by a
supervising clinician who possesses privileges in the particular
procedures or management protocols; and/or
3) Direct proctoring of the LIP in particular procedures or
management protocols by a qualified clinician possessing a degree
of expertise in the particular procedures or protocols beyond the
level of expertise of most newly practicing primary care providers.

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Approval Authority for Initial LIP Credentialing and Privileging
The free clinic’s governing board should state in writing its determination that a
LIP meets credentialing and privileging requirements. This determination can be
based on the recommendation of the Medical Director or the combined
recommendation of medical staff (including the Medical Director) and the
Executive Director. Alternatively, the governing board may delegate this
responsibility (via resolution or bylaws) to an appropriate individual to be
implemented based on approved policies and procedures (including methods to
assess compliance with these policies and procedures).
Examples of cases in which a free clinic could grant temporary privileges to a LIP
in order to meet important patient care needs for a limited period of time include:
1) A current LIP becomes ill or takes a leave of absence, and another LIP is
needed to cover patient care until the current LIP returns; or
2) A current LIP does not have the necessary skills to provide needed patient
care.
Temporary Privileging Requirements for LIPs
The free clinic should strive to complete the privileging process prior to the LIP
being allowed to provide patient care services. However, if the free clinic has
established temporary privileging policies and procedures, it can grant temporary
privileges to a LIP:
1) To meet important patient care needs for a limited period of time4
(requires verification, which can be done by phone, of the provider’s
current licensure and current competence in the specific scope or content
of patient care services he/she is to provide at the free clinic); or
2) To issue privileges for new volunteer free clinic health care professionals
for a period not to exceed 120 days when the following has been verified:
a) Current licensure and lack of any history of current or previously
successful challenges to licensure (can be done by phone);
b) Relevant training and experience (can be done by phone);
c) Current competence in the specific scope or content of patient care
services he/she is to provide at the free clinic and ability to perform
the privileges requested (can be done by phone);
d) NPDB history;
e) Lack of any history of involuntary termination of medical staff
membership at another organization;
f) Lack of any history of involuntary limitations, reduction, denial, or
loss of clinical privileges; and
g) Other criteria required by the policies and procedures of the free
clinic (can be done by phone).
Free clinics should not provide temporary privileges for situations in which:
1) The LIP fails to provide all information necessary for the privileging
process; or

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2) Free clinic staff fails to verify performance data and other information
in a timely manner.
In these situations, the free clinic must require that the LIP cease providing patient
care in the free clinic until the privileging process is completed.
Initial Credentialing of Other Licensed or Certified Practitioners
The initial credentialing of other licensed or certified practitioners should include:
1) Primary source verification current licensure, registration, or certification;
2) Secondary source verification of:
a) Education and training;
b) Identification (via a government issued picture id);
c) Drug Enforcement Administration registration, as applicable;
d) Hospital admitting privileges, as applicable;
e) Immunization and PPD status; and
f) Life support training, as applicable; and
3) Querying the NPDB, as applicable (If the free clinic is ineligible to query
the NPDB, it must have the licensed or certified practitioner provide the
results of a self-query).
A free clinic also may choose to credential other licensed or certified health care
practitioners via similar requirements utilized for LIPs. Free clinics must
complete the credentialing process for other licensed or certified health care
practitioners prior to the practitioners providing patient care services at the free
clinic.
Initial Privileging of Other Licensed or Certified Practitioners
The initial privileging of another licensed or certified practitioner involves the
assessment of his/her current competence in the specific scope or content of
patient care services he/she is to provide at the free clinic. A free clinic can assess
current competency through an orientation process during which a supervisor
evaluates the practitioner’s clinical qualifications and performance based on
his/her job description.
Approval Authority for Initial Credentialing and Privileging of Other Licensed or
Certified Health Care Practitioners
The Executive Director should state in writing his/her determination that an other
licensed or certified health care practitioner meets credentialing and privileging
requirements. This determination should be based on the Medical Director’s
review of credentialing information and the supervisor’s evaluation of the
practitioner’s clinical qualifications and performance.
Alternatively, the Executive Director may delegate this responsibility (via
resolution or bylaws) to an appropriate individual to be implemented based on
approved policies and procedures (including methods to assess compliance with
these policies and procedures).

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Reassessment of the Credentials and Privileges of LIPs and Other Licensed or
Certified Health Care Practitioners
The free clinic should reassess the credentials and privileges of LIPs and other
licensed or certified health care practitioners at least every 2 years. Renewed
credentialing and privileging processes should include:
1) Primary source verification of current licensure, registration or
certification;
2) Secondary source verification of:
a) Adherence to the free clinic’s policies, procedures and rules;
b) Relevant education training and experience (if changed since initial
appointment);
c) The practitioner’s ability to perform the care, treatment and services
he/she has been providing and will be providing in the future at the
free clinic; and
d) Lack of any restrictions on privileges at any other health care
organization.
3) An assessment of current competency to include:
a) A synopsis of peer review results from the prior 2 year period
and/or any relevant performance improvement information (for
LIPs); or
b) The supervisor’s evaluation of performance (for other licensed or
certified health care practitioners); and
4) Querying the NPDB, as applicable.
The free clinic should notify each LIP and other licensed or certified health
care practitioner in writing of its conclusions regarding the reassessment of
the practitioner’s credentials and privileges.
The free clinic should have an appeal process that a LIP can undertake if the
free clinic decides to discontinue or deny his/her clinical privileges. An appeal
process is optional for other licensed or certified health care practitioners.
B. Patient Notice of Limited Legal Liability of FTCA Deemed Health Care
Professionals
A FTCA deemed volunteer free clinic health care professional or the free clinic
must provide each patient with written notification of the limited liability of the
health care professional pursuant to FTCA. The volunteer health care professional
and/or free clinic can satisfy this statutory requirement by having each patient
review a notification document prior to the first encounter between the patient and
the health care professional. It is preferable that the health care practitioner or free
clinic obtain the patient’s signature on the notice and include the notice in the
patient’s medical record. If the volunteer health care professional is providing
emergency care, the health care professional or free clinic may provide the written
notice as soon thereafter as is practicable. The health care professional or free
clinic should provide the notice to a parent or legal guardian when the patient
lacks legal responsibility for his/her care under the law of the State where care is
provided.

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A sample patient notice can be found in Appendix C. Free clinics also may
choose to develop their own patient notice form. The free clinic’s form must at a
minimum address all of the requirements listed in the sample.
VI. HOW ARE CLAIMS PROCESSED?
Claimants alleging acts of medical malpractice by a FTCA deemed volunteer free clinic
health care professional must file their claims against the United States according to
FTCA requirements. FTCA requires that the alleged injured party file an administrative
claim with HHS prior to instituting any court action.
Upon receipt of the claim, HHS will determine whether FTCA medical malpractice
coverage applies to the particular claim by considering if the alleged act or omission
giving rise to the claim:
1) Involved a volunteer free clinic health care professional with deemed FTCA
status pursuant to the PHS Act;
2) Involved a health care service qualifying for FTCA coverage; and
3) Occurred at a free clinic or a covered offsite program or event carried out by the
free clinic.
If HHS denies the claim or HHS action is pending after 6 months, the claimant can file
suit against the United States. FTCA medical malpractice cases are heard in Federal
district court without a jury and are defended by the Department of Justice with the
assistance of the Office of General Counsel, Department of Health and Human Services.
No punitive damages are allowed.
VIII. WHAT IS THE APPLICATION PROCESS?
A. Overview
A free clinic must sponsor each volunteer free clinic health care professional that
participates in the Program. A free clinic can sponsor volunteer free clinic health care
professionals by submitting a FTCA deeming application to the HHS Secretary thru the
Free Clinic FTCA Program. The free clinic can download deeming applications from the
web at http://www.bphc.hrsa.gov/freeclinicsftca/application.htm. Free clinics should
submit:
1) One electronic copy and one hard copy of all application materials to:
[email protected]; or
2) One copy of all application materials to:
Free Clinic FTCA Program
Division of Clinical Quality
Bureau of Primary Health Care, HRSA
5600 Fishers Lane, Room 15C-26
Rockville, MD 20857
Failure to submit any of the requested information will render the application incomplete.
The application will not be considered until the missing information is provided.

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B. Original Deeming Application
A free clinic may submit an original FTCA deeming application at any time after the
effective date of this notice. The original deeming application requires information
fulfilling statutory and programmatic requirements, including (see Appendix A):
1) Contact information of the sponsoring free clinic;
2) Location and managers of free clinic sites;
3) Description of the free clinic’s credentialing and privileging systems;
4) Description of the free clinic’s risk management systems;
5) List of all volunteer health care professionals that the free clinic is sponsoring for
FTCA deemed status (no handwritten lists, please);
6) Description of all medical malpractice claims alleged against the free clinic and/or
its sponsored volunteer health care professionals occurring prior to the submission
of this FTCA application (including pending claims) and a description of all
disciplinary actions against any of the sponsored volunteer health care
professionals;
7) Requested effective date of FTCA coverage; and
8) Approval signatures of senior free clinic managers.
HRSA’s Associate Administrator for Primary Care will make final decisions regarding
FTCA deeming of volunteer free clinic health care professionals within 30 days of receipt
of a complete application. The HRSA Associate Administrator will provide the free clinic
with written notification of the effective date of its volunteer health care professionals’
FTCA deemed status. Original deeming will be valid through the remainder of the
calendar year.
C. Annual Renewal Deeming Application
The free clinic subsequently can sponsor volunteer health care professionals annually by
submitting a FTCA annual renewal application in the month corresponding with its
original deeming application submission.
The HRSA Associate Administrator will make final decisions regarding FTCA deeming
renewal of volunteer free clinic health care professionals. If the renewal application is
approved, in December, the HRSA Associate Administrator will provide the free clinic
with written notification of its volunteer health care professionals’ FTCA deemed status
that will be valid through the subsequent calendar year.
D. Supplemental Deeming Application
If a free clinic desires FTCA coverage of additional volunteer free clinic health care
professionals prior to the due date for the annual renewal application, the free clinic must
submit a supplemental deeming application (see Appendix B) that contains:
1) Contact information of the sponsoring free clinic;
2) Location and managers of any new free clinic sites since its last FTCA application
submission;
3) Certification that the free clinic has maintained its credentialing, privileging, and
risk management systems or a description as to how the system(s) has been
modified;

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4) List of all new volunteer health care professionals that the free clinic is
sponsoring for FTCA deemed status;
5) A description of all medical malpractice claims alleged against the free clinic’s
newly sponsored volunteer health care professionals and a description of all
disciplinary actions against any of the sponsored volunteer health care
professionals;
6) Requested effective date of FTCA coverage; and
7) Approval signatures of senior free clinic managers.
Supplemental deeming will be valid through the remainder of the calendar year.
VIII. TYPES OF RECOMMENDED INSURANCE
The Program provides protection only from allegations of medical negligence for
volunteer free clinic health professionals as defined in Section III of this PIN. Other free
clinic staff and the free clinic corporation are not covered under FTCA. Additionally, the
Program does not provide protection against perils normally protected by general liability
and directors and officers’ insurance policies. Free clinics should consult with their
insurance agents to determine their needs for protection beyond the Program.
IX. 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 0915-0293. Public reporting burden for this
collection of information is estimated to average 16 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 10-33,
Rockville, Maryland, 20857.

X. APPENDICES
Appendix A Deeming Application – Original or Annual Renewal
A.1 – Application Form
A.2 - Application Checklist
Appendix B Deeming Application – Supplemental
B.1 – Application Form
B.2 –Application Checklist
Appendix C Sample Patient Notice of Limited Liability of FTCA Deemed Volunteer Free
Clinic Health Professionals
Appendix D Free Clinic FTCA Deeming Application Feedback Form

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Appendix A.1
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
Volunteer Free Clinic Health Professional Deeming Application – Original or
Annual Renewal (Please note that the free clinic will need to in the future file the annual
renewal applications by July 11.)
SECTION I –SPONSORING FREE CLINIC
Free Clinic FTCA Number:
(Leave blank if original deeming application)
Corporate Name of Free Clinic or Sponsoring Entity:
(If there has been a legal name change since the last application
submission, please attach the appropriate state document indicating the
change.)
List any “doing business as” (dba) name:
Corporate Address:
Chief Executive Officer’s Name:
Telephone Number:
Fax Number:
E-mail:
Free Clinic Medial Director’s Name:
Telephone Number:
Fax Number:
E-mail:
Risk Management Coordinator’s Name:
SECTION II –FREE CLINIC SITES
List all free clinic sites where volunteer health care professionals will be
providing services.
Please make additional copies of this page to list any additional sites.
Free Clinic Site - main or additional (circle one):
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Executive Director’s Name: Telephone Number:
Medical Director’s Name: Telephone Number:

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Free Clinic Site - main or additional (circle one):
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Executive Director’s Name: Telephone Number:
Medical Director’s Name: Telephone Number:

SECTION III – CREDENTIALING AND PRIVILEGING SYSTEMS
Please answer YES or NO to the following questions by marking in the
appropriate box.
“NO” answers require an explanation in Section V.
Note that the credentialing and privileging activities specified below may
be done through the free clinic’s own efforts or through its reasonable
reliance on information provided to it by a credible third party such as a
credentialing verification organization.
Item
Yes
No
A. The free clinic periodically verifies licensure, certification
and/or registration of each volunteer health care professional according to
the instructions in PIN 2004-24 (Revised).

B. The free clinic has a copy of each volunteer health care
professional’s current license, certification, and/or registration on file at
the free clinic.

C. The free clinic periodically verifies board eligibility or
certification for each volunteer health care professional, when applicable,
according to instructions in PIN 2004-24 (Revised).

D. The free clinic utilizes peer review activities when it
periodically privileges volunteer health care professionals according to the
instructions in PIN 2004-24 (Revised).

E. During the credentialing processes, the free clinic requires each
volunteer health care practitioner to submit a personal statement or other
evidence of fitness to perform expected health care duties according to the
instructions in PIN 2004-24 (Revised).

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F. The free clinic has a copy of each volunteer health care
professional’s hospital privileges, when applicable, on file.

G. The free clinic annually reviews each volunteer health care
professional’s history of prior and current FTCA medical malpractice
claims.
H. During the credentialing process of volunteer health care
professionals, the free
clinic queries the National Practitioner Data Bank according to the
instructions in
PIN 2004-24 (Revised).

SECTION IV – RISK MANAGEMENT SYSTEMS
Please answer YES or NO to the following questions by marking in the
appropriate box.
“NO” answers require an explanation in Section V.
Item
Yes
No
A. The free clinic has policies and procedures in place for the
provision of appropriate supervision and back-up of clinical staff.

B. The free clinic maintains a medical record for every patient
receiving care from its organization.

C. The free clinic has policies and procedures that address triage,
walk-in patients and telephone triage.

D. The free clinic has protocols that define appropriate treatment
and diagnostic procedures for selected medical conditions based on
current standards of care.

E. The free clinic has a tracking system for patients who miss
appointments or require follow-up of referrals, hospitalization, x-rays, or
laboratory results.

F. The free clinic periodically reviews patients’ medical records to

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determine quality, completeness and legibility.

G. The free clinic has a written, current quality assurance plan
(please attach a copy).

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

I. The free clinic considers findings from its peer review activities
when reviewing and/or revising its quality assurance plan.

J. The free clinic utilizes quality assurance finding to modify
policies to improve patient care.

K. The free clinic’s volunteer health care professionals annually
participate in risk management continuing education activities.

L. The free clinic has assured that each volunteer health care
professional has a copy of PIN 2004-24 (Revised) and that his/her
questions regarding FTCA medical malpractice coverage have been
addressed.
M. The free clinic has attached a copy of the clinic’s IRS 501©(3)
documentation.

SECTION V – ADDITIONAL INFORMATION REGARDING
CREDENTIALING, PRIVILEGING, AND RISK MANAGEMENT
SYSTEMS
Explanations of each “No” answer from Sections III & IV.
(Please identify each response with the corresponding section number and
letter.)
Please attach additional pages, if needed.

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SECTION VI - FREE
CLINIC VOLUNTEER
HEALTH CARE
PROFESSIONALS
List of all volunteer free
clinic licensed or certified
health care professionals
that the free clinic wants to
sponsor for FTCA deemed
status.
For Renewal Applications,
please also include
separate (typed) lists for (1)
currently covered clinicians
to be continued, (2) any
requested new
supplemental clinicians,
and (3) for clinicians to be
dropped from FTCA
coverage.
Name

Professional
designation
(e.g., MD,
RN, CNM)

Specialty
Training

Specialty
to be
Practiced
at the
Free
Clinic

Home
Address

Home
Phone

Please attach additional sheets, if needed.
Person and Organization Conducting Privileging

16

Date of Last
Credentialing
Person and
Organization
Conducting

Credentialing

Date of
Last
Privileging

BPHC Program Information Notice 2004-24

(Annual renewal deeming) Describe all medical malpractice claims against the free
clinic, its deemed health care professionals, and/or its newly sponsored volunteer health
care professionals since the last FTCA application submission.
SECTION VII – HISTORY OF MEDICAL MALPRACTICE
CLAIMS
(Original deeming) Describe all medical malpractice claims against the
free clinic. Also, describe all malpractice claims against its sponsored
volunteer health care professionals (for at least the last 10 years)
occurring prior to the submission of this FTCA application (unless
reported on a previous application).
Also include a list of any disciplinary actions taken by a State medical
licensing authority (or a professional society) for the relevant volunteer
health care clinicians. Note that clinics should usually avoid applying for
coverage for volunteers who have had prior disciplinary actions.
Please make additional copies of this page to list additional claims.
Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

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BPHC Program Information Notice 2004-24

SECTION VIII – SIGNATURES
REQUESTED EFFECTIVE DATE OF FTCA COVERAGE
______________
(No sooner than 30 days from the date of application submission)
We certify that this sponsoring free clinic meets the definition of a free
clinic found in Section III of HRSA/BPHC PIN 2004-24 (Revised) and
that the information in this application and the related attachments is
complete and accurate.
CHIEF EXECUTIVE OFFICER:
__________________________________________
(Print or type)
SIGNATURE: _______________________________ Date:
________________
FREE CLINIC MEDICAL DIRECTOR:
____________________________________________
(Print or type)
SIGNATURE: _______________________________ Date:
________________

(Note: When filing electronically, an electronic signature is sufficient.)

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BPHC Program Information Notice 2004-24

Appendix A.2
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
APPLICATION
CHECKLIST

Volunteer Free Clinic Health Professional Deeming
Application – Original or Annual Renewal

ITEM COMPLETED AND/OR ATTACHED

( annual renewal application only)
(original deeming) Descriptions of all medical malpractice claims occurring
prior to the submission of this deeming application are included.
Other
APPLICATION SECTION
Section I – Sponsoring Free Clinic
State document indicating legal name change is attached if legal name change occurred
since last deeming application was submitted.
Section II –Free Clinic Sites
All free clinic sites are listed, using additional copies of Section II, if needed.
Each site is appropriately identified as the main or an additional site.
Section III –Credentialing and Privileging Systems
An explanation of all “No” answers is provided in Section V.
The free clinic’s credential and privileging policies are included in the attached quality
assurance plan or as a separate document.
Section IV–Risk Management Systems
An explanation of all “No” answers is provided in Section V.
The free clinic’s risk management policies are included in the attached quality assurance
plan or as a separate document. A copy of the free clinic’s quality assurance plan is
attached.
Section V–Additional Information Regarding Credentialing, Privileging and Risk
Management Systems
An explanation for each “No” answer from Sections III & IV is included.
Section VI – Free Clinic Volunteer Health Care Professionals
All free clinic volunteer health professionals that the free clinic wants to sponsor for
FTCA deemed status are listed.
Section VII– History of Medical Malpractice Claims
(Annual renewal deeming) Descriptions of all medical malpractice claims since the last
deeming application submission are included.
Section VIII– Signatures
Original signatures are included for the Chief Executive Officer and Free Clinic Medical
Director. A copy of the free clinic’s patient notice of limited liability of FTCA deemed
volunteer health care professionals is attached.

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BPHC Program Information Notice 2004-24

Appendix B.1
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
SECTION I –SPONSORING FREE CLINIC
Free Clinic FTCA Number:
Corporate Name of Free Clinic or Sponsoring Entity:
(If there has been a legal name change since the last application submission, please
attach the appropriate state document indicating the change.)
Corporate Address:
Chief Executive Officer’s Name:
Telephone Number:
Fax Number:
E-mail:
Free Clinic Director’s Name:
Telephone Number:
Risk Management Coordinator’s Name:
E-mail:
SECTION II –FREE CLINIC SITES
Please make additional copies of this page to list any additional sites.
Free Clinic Site - main or additional (circle one):
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Medical Director’s Name: Telephone Number:
Free Clinic Site - main or additional (circle one):
Name:
Address:
Telephone Number:
Fax Number:
E-mail:
Days/Hours of Operations:
Executive Director’s Name: Telephone Number:

Volunteer Free Clinic Health Professional Deeming Application - Supplemental
Fax Number:
List all new free clinic sites where volunteer health care professionals have been/will be
providing services (i.e., sites not included in the last deeming application).
Executive Director’s Name: Telephone Number:
Medical Director’s Name: Telephone Number:

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BPHC Program Information Notice 2004-24

SECTION III– CREDENTIALING, PRIVLEGING & RISK MANAGEMENT
SYSTEMS CERTIFICATION
[ ] Has modified the credentialing, privileging, and/or risk management systems since the
submission of its last FTCA deeming application.
Please attach additional sheets, if needed.
___________________________ Free Clinic:
(Print or type free clinic’s name)
(Check appropriate box)
[ ] Has maintained the credentialing, privileging, and risk management systems
documented in its last FTCA deeming application
OR

Please explain any changes in the free clinic’s credentialing, privileging, and risk
management systems.

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BPHC Program Information Notice 2004-24

SECTION IV - FREE CLINIC VOLUNTEER HEALTH CARE
PROFESSIONALS
SECTION IV - FREE
CLINIC VOLUNTEER
HEALTH CARE
PROFESSIONALS
List of all volunteer free
clinic licensed or certified
health care professionals
that the free clinic wants to
sponsor for FTCA deemed
status.
Name

Professional
designation
(e.g., MD,
RN, CNM)

Specialty
Training

22

Specialty
to be
Practiced
at the
Free
Clinic

Home
Address

Home
Phone

Date of Last
Credentialing
Person and
Organization
Conducting

Credentialing

Date of
Last
Privileging

BPHC Program Information Notice 2004-24

SECTION V – HISTORY OF MEDICAL MALPRACTICE CLAIMS
(Original deeming) Describe all medical malpractice claims against the
free clinic. Also, describe all malpractice claims against its sponsored
volunteer health care professionals (for at least the last 10 years)
occurring prior to the submission of this FTCA application (unless
reported on a previous application).
Also include a list of any disciplinary actions taken by a State medical
licensing authority (or a professional society) for the relevant volunteer
health care clinicians. Note that clinics should usually avoid applying for
coverage for volunteers who have had prior disciplinary actions.
Please make additional copies of this page to list additional claims.
Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

Specialty Involved:
Allegation:
Action taken by the free clinic to prevent such claims in the future:

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BPHC Program Information Notice 2004-24

SECTION VI – SIGNATURES
REQUESTED EFFECTIVE DATE OF FTCA COVERAGE FOR
ADDITIONAL VOLUNTEER HEALTH CARE PROFESSIONALS
______________
(No sooner than 30 days from the date of application submission)
We certify that this sponsoring free clinic meets the definition of a free
clinic found in Section III of HRSA/BPHC PIN 2004-24 (Revised) and
that the information in this application and the related attachments is
complete and accurate.
CHIEF EXECUTIVE OFFICER:
__________________________________________
(Print or type)
SIGNATURE: _______________________________ Date:
________________
FREE CLINIC MEDCIAL DIRECTOR:
____________________________________________
(Print or type)
SIGNATURE: _______________________________ Date:
________________
(Note: When filing electronically, an electronic signature is sufficient.)

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BPHC Program Information Notice 2004-24

Appendix B.2
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
ITEM COMPLETED AND/OR ATTACHED
Original signatures are included for the Chief Executive Officer and Free Clinic Director.
APPLICATION
Volunteer Free Clinic Health Professional Deeming
CHECKLIST
Application - Supplemental
APPLICATION SECTION
Section I – Sponsoring Free Clinic
State document indicating legal name change is attached if legal name change occurred
since last deeming application was submitted.
Section II –Free Clinic Sites
Free clinic sites that were not included in the last deeming application are listed, using
additional copies of Section II, if needed.
Each site is appropriately identified as the main or an additional site.
Section III –Credentialing, Privileging, and Risk Management Systems Certification
An explanation of any changes in the free clinic’s credentialing, privileging and/or risk
management systems since the last deeming application submission is included, if
applicable.
Section IV – Free Clinic Volunteer Health Care Professionals
All free clinic health professionals not listed in the last deeming application that the free
clinic wants to sponsor for FTCA deemed status are listed.
Section V– History of Medical Malpractice Claims
Descriptions of all medical malpractice claims occurring since the last deeming
application submission are included.
Section VI– Signatures

25

BPHC Program Information Notice 2004-24

Appendix C
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
Sample Patient Notice of Limited Liability of FTCA Deemed Volunteer Free Clinic
Health Care Professionals
Notice to Patients
To be provided to the individual patient before health care services are provided, except
in emergency cases when notice may be provided as soon after the emergency as is
practicable or to a parent or legal guardian when the patient lacks legal responsibility for
his/her care under State law.
This is to notify you that under Federal law relating to the operation of free clinics, the
Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides
the exclusive remedy for damage from personal injury, including death, resulting from
the performance of medical, surgical, dental, or related functions by any free clinic
volunteer health care practitioner who the Department of Health and Human Services has
deemed to be an employee of the Public Health Service. This FTCA medical malpractice
coverage applies to deemed free clinic volunteer health care practitioners who have
provided a required or authorized service under Title XIX of the Social Security Act (i.e.,
Medicaid Program) at a free clinic site or through offsite programs or events carried out
by the free clinic (See 42 U.S.C. § 233(a), (o)).
The above Federal law and other State and Federal laws including the Federal Volunteer
Protection Act of 1997 may cover certain free clinic health care professionals providing
health care services to patients at this free clinic.
Acknowledged:
________________________________(Patient signature)
________________________________(Patient name, printed legibly)
Date: ____________
Proposed Project: Free Clinic FTCA Deeming Application (OMB No. 0915-0293)
Revision

26

BPHC Program Information Notice 2004-24

Appendix D
FREE CLINIC FEDERAL TORT CLAIMS ACT (FTCA) PROGRAM
Annual Number of Free Clinic Patient Visits Which Are Covered by FTCA
Malpractice Coverage
Free Clinic FC #__________
Please list the annual number of the free clinic’s patient visits which are covered by the
FTCA malpractice coverage. This data should be reported for the calendar year. This
data should be sent to The Bureau of Primary Health Care by February 28 for the prior
calendar year. (I.e., the annual number of the free clinic’s patient visits which are covered
by the FTCA malpractice coverage for the year 2009, should be reported to The Bureau
of Primary Health Care by February 28, 2010.)
For the year _____________, the annual number of the free clinic’s patient visits,
which are covered by the FTCA malpractice coverage, is ________________ patient
visits.
This annual data should preferably be sent by email to the Bureau Free Clinic FTCA
Program, FTCA Patient Visits Data Report, c/o Mike Chellis at [email protected] with
an email cc to [email protected]. (Please always include your free clinic FTCA
# (FC00xx) in the subject line of these emails other communications with the Free Clinic
FTCA Program.

27