Form 1 Attachment A_0293 FTCA Deeming Application 09.14.17

OMB No.: 0915-0293
Expiration Date: XX/XX/20XX

Federal Tort Claims Act (FTCA) Program Deeming Application for Free Clinics

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:
*Send state documentation indicating legal name change if legal name change occurred
since last deeming application.

Section II. Site Information

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




Name:
Address:
Phone Number:
Fax Number:
E-mail:
Site Type:

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
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 14N39, Rockville, MD 20857.

OMB No.: 0915-0293
Expiration Date: XX/XX/20XX

 Days/Hours of Operations:
*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. The sponsoring free clinic is a registered nonprofit organization. (Please attach
documentation if an Initial Applicant)
[ ] Yes
[ ] No (If no, then explain)
2. The sponsoring free clinic and its health professionals comply with the statutory and
Program definitions relative to covered individuals as set forth in PIN 2011-02.
[ ] Yes
[ ] No (If no, then explain)
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
[ ] No (If no, then explain)
4. The free clinic does not impose charges on patients either based on service provided or
the ability to pay.
[ ] Yes
[ ] No (If no, then explain)
5. The free clinic accepts patients’ voluntary donations for services provided.
[ ] Yes
[ ] No (If no, then explain)
6. The free clinic is licensed or certified to provide health services in accordance with
applicable state law.
[ ] Yes
[ ] No (If no, then explain)
7. The free clinic and/or individual health care professional provides a patient a written
notification explaining that the patients’ legal liability is limited pursuant to the Public
Health Service Act.
[ ] Yes
[ ] No (If no, then explain)

Section IV. Credentialing and Privileging Systems*
1. The free clinic periodically verifies licensure, certification and/or registration of each
volunteer health care professional according to the instructions in this PIN 2011-02.
[ ] Yes
[ ] No (If no, then explain)
2. The free clinic has a copy of each volunteer health care professional’s current license,
and/or registration on file at the free clinic.
[ ] Yes

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[ ] No (If no, then explain)
3. The free clinic periodically verifies board eligibility or certification for each volunteer
health care professional, when applicable, according to instructions in this PIN 2011-02.
[ ] Yes
[ ] No (If no, then explain)
4. If the free clinic uses a hospital to serve as a CVO, there is a written contractual
agreement stating the specifics of the expected CVO services.
[ ] Yes
[ ] No (If no, then explain)
5. The free clinic utilizes peer review activities when it periodically privileges volunteer
health care professionals every two years according to the instructions in PIN 2011-02.
[ ] Yes
[ ] No (If no, then explain)
6. The free clinic has a copy of each volunteer health care professional’s hospital
privileges, when applicable, on file.
[ ] Yes
[ ] No (If no, then explain)
7. The free clinic annually reviews each volunteer health care professional’s history of
prior and current medical malpractice claims.
[ ] Yes
[ ] No (If no, then explain)
8. A National Practitioner Data Bank (NPDB) query is obtained and evaluated every two
years for each licensed and certified health care professional according to the
instructions in PIN 2011-02.
[ ] Yes
[ ] No (If no, then explain)
9. 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.
*Required for Initial and Redeeming applications. Required for Supplemental
applications if the free clinic has changed its credentialing and privileging system since
the annual deeming application.

Section V. Risk Management Systems*
1. The free clinic has policies and procedures in place 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 those 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

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b. Walk-in patients [ ] Yes [ ] No
c. Telephone triage [ ] Yes [ ] No
If answered No for any of the above, then explain.
4. The free clinic has protocols that define appropriate treatment and diagnostic
procedures for selected medical conditions 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, x-rays, or laboratory results.
[ ] Yes
[ ] No (If no, then explain)
6. The free clinic periodically reviews patients’ medical records to determine quality,
completeness, and legibility.
[ ] Yes
[ ] No (If no, then explain)
7. The free clinic has a written, current quality assurance plan that clearly addresses the
clinic’s credentialing and privileging process and has been signed by a board authorized
representative within the past three years (please attach a copy of the plan with board
approval date).
[ ] Yes
[ ] No (If no, then explain)
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 quality assurance plan.
[ ] Yes (If yes, what information and process is utilized by the clinic when updating and
revising the quality assurance 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 volunteer health care professionals 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.
[ ] Yes
[ ] No (If no, then explain)

OMB No.: 0915-0293
Expiration Date: XX/XX/20XX

*Required for Initial and Redeeming applications. Required for Supplemental
applications if the free clinic has changed its QI/QA Plan since the last renewal deeming
application.

Section VI. Free Clinic Individuals (Volunteer Health Care 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:
Credentialing and Privileging
 Date of Last Credentialing:
 Date of Last Privileging:
(Please remember that all state licensed
or certified health professionals need to
be credentialed and privileged every
two years. Not mandatory for ‘Board
Members’ and ‘Executive’ role.)
Medical Malpractice
 Individual Type:
o New Applicant
o Renewal Applicant
 Employee Type:
o Employee
o Volunteer
 Medical Malpractice Claims
(against the individual):
o Yes
o No
o N/A
Enter Your Comments
 Comments:

OMB No.: 0915-0293
Expiration Date: XX/XX/20XX

(Comments are required for individuals
with Medical Malpractice Claims)
*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.
 Provide a physical address for 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. Physical
addresses and phone numbers provided for individuals must be personal mailing
addresses that are different than that of the clinic.
 Specify the person’s role in the free clinic for any individual the free clinic is
sponsoring for FTCA deemed status. Disclose if the individual has had any past
medical malpractice claims or disciplinary actions for the past ten (10) years if
submitting an initial or supplemental application or for the past five (5) years for
redeeming applicants.
 Attach an explanation of each medical malpractice claim or disciplinary action
(to include probationary actions) including explanations of the suit, 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.

Section VII. Patient Visit Data
1. Total number of FTCA deemed individuals, in the
recently closed calendar year:
2. Total number of FTCA deemed providers, in the
recently closed calendar year:
3. Total number of patient visits conducted by FTCA
deemed individuals, in the recently closed calendar year:

Section VIII. Attachments
Attachment A. Non Profit Documentation (Maximum 5)
Required for Initial applications only.
Attachment B. Copy of Clinic’s QI/QA Plan (Maximum 5)
Please attach the free clinic’s QI/QA Plan that has been approved, signed, and dated by a
board authorized representative within the past three years:
 Required for Initial and Redeeming applications.
 Required for Supplemental applications if the free clinic has changed its QI/QA
Plan since the last renewal deeming application.

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Expiration Date: XX/XX/20XX

Attachment C. Medical Malpractice Claims and Disciplinary Actions
Attach an explanation of each medical malpractice claim or disciplinary action (to
include probationary actions) including explanations of the suit, 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.
Attachment D. Other supporting Documentation (Maximum 5)
Please attach any other supporting documentation.

Section IX. Remarks
Is the coverage requested for an offsite event?
[ ] Yes. (Enter descriptive information about the offsite events. Please enter the type of service
provided and location of the event.)
[ ] No
Record Remarks
If yes to the above question on an offsite event, enter descriptive information here.
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:
[email protected].
[ ] 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 HRSA/BPHC PIN 2011-02 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.