Form 1 FTCA VHP Application

OMB No.: 0906-XXXX

Expiration Date: XX/XX/20XX

Federal Tort Claims Act (FTCA) Health Center Volunteer Health Professional Program Application

Department of Health and Human Services Health Resources and Services Administration
OMB #	Grantee Name	Grant Number
Contact Information

CONTACT INFORMATION (Please include salutation next to the name) All the fields marked with * are required.
EXECUTIVE DIRECTOR (Must electronically sign and certify the volunteer health professional application prior to submission) * Name: * Email: * Direct Phone: Fax:

Section I. Sponsoring Health Center Acknowledgments 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 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 denied or otherwise disapproved, none of its listed volunteers will be eligible to become deemed PHS employees 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 will be utilized by HRSA in reaching its determination as to whether the health center entity is a deemed PHS employee, as required to sponsor health center volunteers for deemed PHS employment.

[ ] Yes [ ] No

Additional Questions:

1. Since the approval of the sponsoring health center’s most recently submitted and approved FTCA deeming or redeeming application, have any changes been made to the health center’s risk management and/or claims management processes?

[ ] Yes [ ] No

If Yes, please describe these changes and attach supporting documentation, if applicable.

>> Comment Box (7,000 Characters)

>> Attachment Section (Optional)

2. Is the health center currently in compliance with credentialing and privileging and quality improvement/quality assurance (QI/QA) FTCA deeming application requirements such that there are no conditions in those areas upon its Health Center Program award?

(Please note that if certain conditions exists in the areas of credentialing and privileging and or QI/QA this is grounds for disapproval of the volunteer health professionals listed in this applications.)

[ ] Yes [ ] No

If No, please explain

>> Comment Box [ 2,000 Characters]

Section II. Volunteer Health Professional: Acknowledgment of Required Performance Conditions

The applicant health center acknowledges its understanding that, for a volunteer to be considered a volunteer health professional (VHP) of a sponsoring deemed health center, the following requirements must be met:

1. The service(s) provided by the VHP(s) to patients at the sponsoring health center’s facilities (including its approved service sites) or through offsite programs or events is carried out by a sponsoring health center (section 224(q)(1)(A)).

[ ] Yes

2. The VHP(s) does not receive any compensation for the service(s) from the patient, the sponsoring deemed health center, or any third-party payer (including reimbursement under any insurance policy, health plan, or federal or state health benefits program); however, 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, including travel expenses to or from the site of services (section 224(q)(1)(C)).

[ ] Yes

3. Before the service(s) is provided, the VHP(s) or the sponsoring deemed health center will post 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)(1)(D)).

[ ] Yes

4. At the time 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)(1)(E)).

[ ] Yes

5. The sponsoring health center maintains all relevant documentation certifying that the volunteer health professional meets the requirements to be considered a volunteer (section 224(q)(1)(F)).

[ ] Yes

The applicant health center acknowledges its understanding that for each volunteer health professional (VHP) the following is required:

6. The sponsoring health center must credentialed and privileged the volunteer health professional in accordance with all current Health Center Program and FTCA Program credentialing and privileging requirements and maintains this information in a file for each volunteer health professional (section 224(q)(3)).

[ ] Yes

Section III. Volunteers for Whom Deeming is Sought
(The sponsoring health center must NOT include other individuals, such as employees, contractors, governing board members and officers on this listing.)
Add Individual Details* Prefix: First Name: Middle Name: Last Name: Professional Designation:
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:
Roles and Specialty Role(s) in Health Center: Specialty: Others: [Please upload a signed volunteer agreement for each individually named volunteer which clearly states that the named volunteer is a volunteer of the health center, outlines the terms and conditions of the services that the volunteer will provide, acknowledges that the volunteer will not receive any compensation including reimbursement from any third party payor, and documents each off-site activity for the provider.]
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 at least every two years.) Please indicate whether the individual volunteer is required to be licensed or certified in accordance with applicable state and federal law(s). [ ] Yes [ ] No If no, please explain. If yes, please upload primary source verification of current licensure and/or certification. (upload attachment)
Medical Malpractice History Please describe any and all (1) state board disciplinary actions and (2) state or federal court (including any FTCA) malpractice claims against the sponsored eligible individuals within ten (10) years prior to the submission of this FTCA volunteer health professional deeming application (including administrative and litigation claims, including pending claims).
*Notes: Please note that within the EHB System, the sponsoring health center is required to submit the information outlined above in section II for each individual volunteer for whom it is seeking FTCA coverage. Provide contact information for all/each health center volunteer health professionals the health center is sponsoring for FTCA deemed status. Both work and personal addresses are requested. If the health center does not or cannot answer “yes” to the questions in section I: questions 1 & 2, and section II: questions 1-5, then the application will be marked “VOID” as nonresponsive and not acted upon by HRSA.

Section IV. Offsite Events and Particularized Determinations

The sponsoring health center acknowledges its understanding that all services provided by volunteer health professionals must be within the sponsoring health center’s approved scope of project for deeming/FTCA coverage to be applicable.. HRSA considers such offsite programs and/or events to include health fairs or similar events where the sponsoring health center provides routine health screenings and educational activities, as well as the activities listed in section C.4 and C.5 of the FTCA Health Center Policy Manual. Any other offsite programs and/or events must be approved via the Particularized Determination process, which is outlined in section C.4 of the FTCA Policy Manual and can be submitted to [email protected].)

Yes [ ] No [ ]

Section V. Signatures

Certification and Signature

I, ______________ (Executive Director)*, 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.

*The application must be signed by the Executive Director, as indicated Section I. Contact Information.

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 0906–XXXX. 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.