Tracked Changes PDF

Application for Health Center Program GranteeAward Recipientss for
Medical Malpractice CoverageLiability Protections Under the
Federal Tort Claims Act
(This application is illustrative and the actual application may appear differently in the HRSA
Electronic Handbook (EHBs) System)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CONTACT INFORMATION

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

CONTACT INFORMATION (Please include a preferred title next to the name)
All the fields in the Contact Information section marked with * are required.
EXECUTIVE DIRECTOR (Must electronically sign
and certify the FTCA application prior to
submission)
* Name:
* Email:
* Direct Phone:
Fax:
GOVERNING BOARD CHAIRPERSON
* Name:
* Email:
* Direct Phone:
Fax:
MEDICAL DIRECTOR
* Name:
* Email:
* Direct Phone:
Fax:
RISK MANAGER
* Name:
* Email:
* Direct Phone:
Fax:

CONTACT INFORMATION (Please include a preferred title next to the name)
All the fields in the Contact Information section marked with * are required.
PRIMARY DEEMING CONTACT
(Individual responsible for completing
application)
* Name:
* Email:
* Direct Phone:
Fax:
ALTERNATE DEEMING CONTACT
(Individual responsible for assisting with the
application)
* Name:
* Email:
* Direct Phone:
Fax:
CREDENTIALING/PRIVILEGING CONTACT
(Individual responsible for managing the
updating credentialing and privileging
processinformation)
* Name:
* Email:
* Direct Phone:
Fax:
CLAIMS MANAGEMENT CONTACT
(Individual responsible for the management and
processing of FTCA and other medical
malpractice claims)
* Name:
* Email:
* Direct Phone:
Fax:
QUALITY IMPROVEMENT/QUALITY ASSURANCE
CONTACT
(Individual responsible for overseeing the QI/QA
program)
* Name:
* Email:
* Direct Phone:
Fax:

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY

Formatted Table

GranteeAward Recipient
Application Type
Name
Application Tracking
Number

REVIEW OF RISK MANAGEMENT SYSTEMS

Grant Number

REVIEW OF RISK MANAGEMENT SYSTEMS
All questions in this sectionfields marked with * are required.
1(A). *I attest that my health center has implemented an ongoing risk management program to
reduce the risk of adverse outcomes that could result in medical malpractice or other health or
health-related litigation and that requires the following.:n. I also acknowledge and agree that
failure to implement an ongoing risk management program and provide documentation of such
implementation may result in disapproval of this deeming application.
i.
Risk management across the full range of health center activities (for example,
patient management including scheduling, triage, intake, tracking, and follow-up);
ii.
Health care risk management training for health center staff;
iii.
Completion of quarterly risk management assessments by the health center; and
iv.
Annual reporting to the board of: completed risk management activities; status of
the health center’s performance relative to established risk management goals; and
proposed risk management activities that relate and/or respond to identified areas
of high organizational risk.
Yes [ ] No [ ]
If “No”, please enterprovide an explanation.
[2,000 character comment box]
1(B). I also acknowledge and agree that failure to implement an ongoing risk management program
and provide documentation of such implementation may result in disapproval of this deeming
application and/or other remedies.
Yes [ ] No [ ]
If “No”, provide an explanation.
[2,000 character comment box]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY

Formatted Table

GranteeAward Recipient
Application Type
Name
Application Tracking
Number

REVIEW OF RISK MANAGEMENT SYSTEMS

Grant Number

REVIEW OF RISK MANAGEMENT SYSTEMS
All questions in this sectionfields marked with * are required.
2. *I attest that my health center has implemented and maintains board-approved (by the board
or designated approving official of the board) risk management policies and procedures to reduce
the risk of adverse outcomes that could result in medical malpractice or other health or healthrelated litigation. The policy and procedures may be in either a single document or maintained
separately, but At a minimum, the policyse policies should specifically address the following:
i. Risk management across the full range of health center activities (for
example, patient management including scheduling, triage, intake, tracking,
and follow-up);
ii. Health care risk management training for health center staff;
iii. Completion of quarterly risk management assessments by the health center;
and
iv. Annual reporting to the board of: completed risk management activities;
status of the health center’s performance relative to established risk
management goals; and proposed risk management activities that relate
and/or respond to identified areas of high organizational risk.
I also acknowledge and agree that failure to implement and maintain a risk management policy and
procedures as further described above to reduce the risk of adverse outcomes that could result in
medical malpractice or other health or health-related litigation may result in disapproval of this
deeming application.
Yes [ ] No [ ]
If “No”, please enter an explanation.
[2,000 character comment box] board-approvedand procedures and Procedures

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23(A). *I attest that my health center has implemented board-approved risk management
operating procedures to reduce the risk of adverse outcomes that could result in medical
malpractice or other health or health-related litigation. At a minimum, these operating procedures
specifically address the following:
i.
Identifying and mitigating (for example, through clinical protocols, medical staff
supervision) the health care areas/activities of highest risk for within health center
patient safety consistent with the health center’s HRSA-approved scope of project,
including but not limited to tracking referrals, diagnostics, and hospital admissions
ordered by health center providers;
ii.
Mitigating the areas/activities of highest risk for health center patient safety
consistent with the health center’s HRSA-approved scope of project, through clinical
protocols, training, and medical staff supervision);
iii.ii.
Documenting, analyzing, and addressing clinically-related complaints, and “near
misses” reported by health center employees, patients, and other individuals;
iv.iii.
Setting and tracking progress related to annual risk management goals;
v.iv.
Developing and implementing an annual health care risk management training plan
for all staff members based on identified areas/activities of highest clinical risk for
the health center (including, but not limited to obstetrical procedures, infection
control) and any non-clinical trainings appropriate for health center staff (including
Health Insurance Portability and Accountability Act (HIPAA) medical record
confidentiality requirements); and
vi.v.
Completing an annual risk management report for the board and key management
staff.
Yes [ ] No [ ]
If “No”, provide an explanation.
[2,000 character comment box]
2(B). I also acknowledge and agree that failure to implement and maintain risk management
procedures as further described above to reduce the risk of adverse outcomes that could result in
medical malpractice or other health or health-related litigation, as further described above, may
result in disapproval of this deeming application.
Yes [ ] No [ ]
If “No”, provide please enter an explanation.
[2,000 character comment box]

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2(C). Upload the risk management procedures that address the items outlined in question 2(A).i
above, specifically risk management procedures that address mitigating risk in referral tracking,
diagnostics, and hospital admissions ordered by health center providers or initiated by the patient.
[Attachment control named ‘Referral Tracking’]
[Attachment control named ‘Hospitalization Tracking’]
[Attachment control named ‘Diagnostic Tracking (must include labs and x-rays)’]

4. *Upload policies or procedures for the following, in order to demonstrate how the health center
has mitigated risk for health center patient safety in these areas/activities consistent with the
health center’s HRSA-approved scope of project:
•
Referral tracking
•
Hospitalization tracking
•
Diagnostic tracking (x-ray, labs)

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[Attachment control named ‘Referral Tracking’]
[Attachment control named ‘Hospitalization Tracking’]
[Attachment control named ‘Diagnostic Tracking (must include labs and x-rays)’]
35(A). *I attest that my health center has developed and implemented an annual health care risk
management training plan for staff members based on identified areas/activities of highest clinical
risk for the health center. These training plans include detailed information related to the health
center’s tracking/documentation methods to ensure that trainings have been completed by the
appropriate staff, including all clinical staff, at least annually.
I attest that the training plans at a minimum also incorporate the following:
i.
Obstetrical procedures (for examplee.g., continuing education for electronic fetal
monitoring (such as, the online course available through ECRI Institute), and
dystocia drills). Please note: Health centers that provide obstetrical services through
health center providers need to include obstetrical training as part of their risk
management training plans to demonstrate compliance. This includes health
centers that provide prenatal and postpartum care through health center providers,
even if they do not provide labor and delivery services;
ii.
Infection control and sterilization (for examplee.g., Blood Borne Pathogen Exposure
protocol, Infection Prevention and Control policies, Hand Hygiene training and
monitoring program, and dental equipment sterilization);
iii.
HIPAA medical record confidentiality requirements; and.
iii.iv.
Specific trainings for groups of providers that perform various services which may
lead to potential risk (for example, dental, pharmacy, family practice).
Yes [ ] No [ ]
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If “No”, provide please enter an explanation.
[2,000 character comment box]
35(B). *Upload the health center’s current annual risk management training plans for all staff
members, including all clinical and non-clinical staff, based on identified areas/activities of highest
clinical risk for the health center and that include at a minimum the items outlined in risk
management question 3(A).i-iv of this application. The risk management training plans should also
include procedures on how document completion of all attendance at required training. to
account for and address individuals who miss scheduled trainings.
All documents must be from the current or previous calendar year. Any documents
dated outside of this period will not be accepted.
[Attachment control named ‘Risk Management Training Plan’]
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3(C). Upload, as well as any and all tracking/documentation methods or tools used to ensure
trainings have been completed by the appropriate staff, including all clinical staffall staff, at least
annually (for example, excel sheet, Relias training reports).
All documents must be from the current or previous calendar year. Any documents
dated outside of this period will not be accepted.
[Aattachment control named ‘Risk Management Training Plan Tracking and
Documentation Tools’]
*46. Upload documentation (for example, data/trends, reports, risk management committee
minutes) that demonstrates that the health center has completed quarterly risk management
assessments.
[Attachment control named ‘Risk Management Quarterly Assessments Documentation’]
Upload the most recent report to the board/key management staff on risk
management activities, progress in meeting risk management goals and evidence
that related follow up actions have been implemented.
5(A). Upload the most recent report provided to the board and key management staff on health
care risk management activities and progress in meeting goals at least annually, and
documentation provided to the board and key management staff showing that any related followup actions have been implemented. The report must be from the current or previous calendar
year and must be reflective of the activities related to risk over a 12-month period. Any
documents dated outside of this period will not be accepted. The report must include:
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i.
ii.

iii.

Completed risk management activities (for example, risk management projects,
assessments),
Status of the health center’s performance relative to established risk management
goals (for example, data and trends analyses, including, but not limited to, sentinel
events, adverse events, near misses, falls, wait times, patient satisfaction
information, other risk management data points selected by the health center), and
Proposed risk management activities for the next 12-month period that relate
and/or respond to identified areas of high organizational risk.

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[Attachment control named ‘Annual Risk Management Report to Board and Key
Management Staff’]

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5(B). Upload proof that the health center board has received and reviewed the report uploaded for
risk management question 5(A) of this application (for example, minutes signed by the board
chair/board secretary, minutes and signed letter from board chair/board secretary).
All documents must be from the current or previous calendar year. Any documents
dated outside of this period will not be accepted.
[Attachment control named ‘Reports to Board and Key Management StaffProof of Board
Review of Annual Risk Management Report’]

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7. *
6. Upload the relevant Position Description(s) of the risk manager who isdescribing the person
responsible for the coordination of health center risk management activities and any other
associated risk management activities. The job description must clearly detail that the risk
management activities are a part of the risk manager’s daily responsibilities.
[Attachment control named ‘Risk Management Position Descriptions’]
78(A). Has the designated individual(s) who oversees and coordinates the health center’s risk
management activitiesthe health center risk manager completed health care risk management
training in the last 12 months (CY2018 or CY2019)?

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[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]
7(B). Upload evidence that the risk manager has completed health care risk management training
in the last 12 months (CY2018 or CY2019).
[Attachment control named ‘Annual Risk Manager Training’]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

QUALITY IMPROVEMENT/QUALITY ASSURANCE
PLAN (QI/QA)

QUALITY IMPROVEMENT/QUALITY ASSURANCE (QI/QA)
All questions in this section fields marked with * are required.

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1(A). I attest that my health center has board-approved policies (for example, a QI/QA plan) that
demonstrate that the health center has an established QI/QA program. Such documentation
must, at a minimum, demonstrate that the QI/QA program addresses the following:
i.
The quality and utilization of health center services;
ii.
Patient satisfaction and patient grievance processes; and
iii.
Patient safety, including adverse events.
[Attachment control named ‘QI/QA Policies’]

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If you are unable to upload the QI/QA Policies that demonstrate the above, provide an
explanation:
[2,000 character comment box]
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1(B). 1. * I attest that my health center has Upload the health center’s QI/QA program operating
procedures or processes that, at a minimum, address the following:policies and supporting
documentation to demonstrate that t the health center has established an ongoing QI/QA
Program and supporting operating procedures.
All supporting documentation must be from the current calendar year or the previous calendar
year. Examples of supporting documentation include, but are not limited to QI/QA minutes and
QI/QA reports. The policies and other documentation must, at a minimum, demonstrate that the
health center’s QI/QA program’s operating procedures address:

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a.i.
b.ii.

Adheringence to current evidence-based clinical guidelines, standards of care, and
standards of practice in the provision of health center services, as applicable;
IA process for identifying, analyzing, and addressing patient safety and adverse
events and for implementing follow-up actions, as necessary;
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c.iii.
d.iv.
e.v.

A process for aAssessing patient satisfaction;
A process for hHearing and resolving patient grievances;
Completingon of periodic QI/QA assessments on at least a quarterly basis to inform
the modification of the provision of health center services, as appropriate; and
f. A process for modifying the provision of health center services based on the
findings of QI/QA assessments, as appropriateProducing and sharing reports on
QI/QA to support decision-making and oversight by key management staff and by
the governing board regarding the provision of health center services.

vi.

[Attachment control named ‘QI/QA Operating Procedures’]
[Attachment control named ‘Supporting QI/QA Documents]
[Attachment control named ‘QI/QA Plan’]

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If you are unable to upload the QI/QA Plan Operating Procedures and/or other
documentation that demonstrates the above, please explainprovide an explanation:
[2,000 character comment box]
2. *Upload documentation that the health center has performed QI/QA assessments on a
quarterly basis (for example, through QI/QA report(s), QI/QA committee minutes, or QI/QA
assessments).
All documents must be from the current or previous calendar year. Any documents dated
outside of this period will not be accepted.

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Such documentation must, at a minimum, demonstrate the following:

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A.i.

B.ii.

QI/QA assessments have been completed on at least a quarterly basis over the past
calendar year by the health center’s physicians or other licensed health care
professionals; and
QI/QA assessments over the past calendar year that include assessing the following:
i.a. Provider adherence to current evidence-based clinical guidance, standards of
care, and standards of practice in the provision of health center services, as
applicable; and; and
ii.b.The identification of any patient safety and adverse events and the
implementation of related follow-up actions, as necessary.
[Attachment control named ‘QI/QA Assessments’]
If you are unable to upload documentation that demonstrates the above, provide an
explanationplease explain:

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[2,000 character comment box]
3(A). *Upload the most recent QI/QA report that has been provided to key management staff and
to the governing board. The report must be from the current calendar year or the previous
calendar year.

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[Attachment control named ‘QI/QA Report’]
3(B). *Upload governing board minutes or other documentation to demonstrate that document
that the QI/QA report uploaded for question 3(A) was shared with and discussed by key
management staff and by the governing board to support decision-making and oversight regarding
the provision of health center services. The minutes should include reference to the report
uploaded for QI/QA question 3(A) in this application. The minutes must be from the current
calendar year or the previous calendar year.
[Attachment control named ‘Governing Board Minutes’]

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4. *Upload the relevant Position Description(s) that describe the responsibilities of the
individual(s) who oversee the QI/QA program, including ensuring the implementation of QI/QA
operating procedures and completion of QI/QA assessments, monitoring QI/QA outcomes, and
updating QI/QA operating procedures. The job description must clearly detail that the QI/QA
activities are a part of the individual’s daily responsibilities.
[Attachment control named ‘QI/QA Position Descriptions’]
5. *Has the health center implemented a certified Electronic Health Record for all health center
patients?

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[ ] Yes [ ] No
If No, please describe the health center’s systems and procedures for maintaining a
retrievable health record for each patient, the format and content of which is consistent
with both federal and state law requirements.
[4,000 character comment box]
6(A). *I attest that my health center has implemented systems and procedures for protecting the
confidentiality of patient information and safeguarding this information against loss, destruction,
or unauthorized use, consistent with federal and state requirements.
[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]

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6(B). I also acknowledge and agree that failure to implement and maintain systems and
procedures for protection the confidentiality of patient information and safeguarding this
information against loss, destruction, or unauthorized use, consistent with federal and state
requirements, may result in disapproval of this deeming application.
[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]
7. *IPlease indicate whether you currently have an active condition or any other enforcement
action on your Health Center Program award related to QI/QA.
[ ] Yes [ ] No

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If Yes, please indicate the date that the condition was imposed and its source (for
example, Operational Site Visit, Service Area Competition application) through which
your organization entity received this condition. Please alsoAlso indicate the specific
nature of the condition, including the finding and reason why the condition was
imposed. Please also dDescribe your organization’s entity’s plan to remedy the
deficiency that led to imposition of the condition and the anticipated timeline by which
the plan is expected to be fully implemented.
[2,000 character comment box]
Please note: The presence of certain award conditions and/or enforcement actions related to
quality improvement / quality assurance may demonstrate noncompliance with FTCA Program
requirements and may result in disapproval of deemed status.

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CREDENTIALING AND PRIVILEGING
All questions in this sectionfields marked with * are required.
1(A). *I attest that my health center has implemented a credentialing process for all clinical staff
members (including for licensed independent practitioners and other licensed or certified health
care practitioners ) who are health center employees, individual contractors, or volunteers). I also
attest that my health center has operating procedures for the initial and recurring review of
credentials, and responsibility for ensuring verification of all of the following:
a.i.
Current licensure, registration, or certification using a primary source;
b.ii.
Education and training for initial credentialing, using:
•a. Primary sources for licensed independent practitioners;
•b. Primary or other sources for other licensed or certified practitioners and any
other clinical staff;
c.iii.
Completion of a query through the National Practitioner Databank (NPDB);
d.iv.
Clinical staff member’s identity for initial credentialing using a government issued
picture identification;
e.v.
Drug Enforcement Administration registration (if applicable); and
f.vi.
Current documentation of Basic Life Support trainingskills.

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[ ] Yes [ ] No
If “No”, provide an explanation.
[2,000 character comment box]
1(B). I also acknowledge and agree that failure to implement and maintain a credentialing process
as further described above may result in disapproval of this deeming application.
[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]

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2(A). *I attest that my health center has implemented a privileging process procedures for the
initial granting and renewal of privileges for clinical staff members (including for licensed
independent practitioners and other licensed or certified health care practitioners who are ,
including health center employees, individual contractors, and volunteers). I also attest that my
health center has operating privileging procedures that address all of the following:
a.i.
Verification of fitness for duty, immunization, and communicable disease status;
b.ii.
For initial privileging, verification of current clinical competence via training,
education, and, as available, reference reviews;
c.iii.
For renewal of privileges, verification of current clinical competence via peer review
or other comparable methods (for example, supervisory performance reviews); and
d.iv.
Process for denying, modifying or removing privileges based on assessments of
clinical competence and/or fitness for duty.

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[ ] Yes [ ] No
If “No”, provide an explanation.
[2,000 character comment box]
2(B). I also acknowledge and agree that failure to implement and maintain a privileging process for
the initial granting and renewal of privileges for clinical staff members, including operating
procedures as further described above, may result in disapproval of this deeming application.

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[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]
3. * UPlease upload the health center’s credentialing and privileging operating procedures that
address all credentialing and privileging elements components listed in questions 1(A) & 2(A) 1 & 2
above. (Please note: Procedures that are missing any of the components referenced in the
credentialing and privileging section questions 1(A) & 2(A) of this application will be interpreted as
the health center not implementing those missing components.)
[aAttachment control named ‘Credentialing and Privileging Operating Procedures’]

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4. *I attest that my health center ensures maintains that the files or records for our clinical staff
(for example, employees, individual contractors, and volunteers) that contain documentation of
licensure, and credentialing verification and recording ofapplicable privileges, consistent with the
health center’s operating procedures.
[ ] Yes [ ] No
If “No”, provide please enter an explanation.
[2,000 character comment box]
5. *I attest that if my health center has contracts with provider organizations (for example, group
practices, staffing agencies) or has formal, written referral agreements with other provider
organizations that provide services within its scope of project, the health center ensures (for
example, through provisions in, such contracts and/or formal, written referral agreements,
contracts, other documentation) contain provisions that such providers are:
i.
a. LEnsure that the providers are licensed, certified, or registered as verified
through a credentialing process, in accordance with applicable federal, state, and
local laws; and
ii.
b. Ensure that the providers are assessed as cCompetent and fit to perform the
contracted or referred services, as assessed through a privileging process.
Select N/A if the health center does not contract with provider organizations or have
any formal, written referral agreements with other provider organizations.

Commented [MK(1]: FTCA recommends keeping this
parenthetical statement as is: this parenthetical statement
slightly differs from the Compliance Manual’s “(for example,
group practices, locum tenens staffing agencies, training
programs)”- because FTCA does not apply for locum tenens
providers or training programs providers.
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[ ] Yes [ ] No [ ] N/A

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If No, provide please enter an explanation.
[2,000 character comment box]
Please note: “A contract between a covered entity and a provider's corporation does not confer
FTCA coverage on the provider. Services provided strictly pursuant to a contract between a
covered entity and any corporation, including eponymous professional corporations (defined as a
professional corporation to which one has given one’s name, for examplee.g., John Doe, LLC, and
consisting of only one health care provider), are not covered under FSHCAA and the FTCA.” See
FTCA Health Center Policy Manual, Section B.3.

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6.* Indicate whether you currently have an active condition or any other enforcement action on
your Health Center Program award related to Please indicate whether you currently have a
condition on your Health Center Program award or other enforcement action related to
credentialing or privileging.
[ ] Yes [ ] No
If Yes, please indicate the date and source (for example, Operational Site Visit, Service
Area Competition application) through which your received this condition or other
enforcement action. Please Aalso indicate the specific nature of the condition or other
enforcement action, including the finding and reason why it the condition was imposed,
such as failure to verify licensure, etc. Please also dDescribe your organization’s entity’s
plan to remedy the deficiency that led to imposition of the condition or enforcement
action and the anticipated timeline by which the plan is expected to be fully
implemented.
[2,000 character comment box]
Please note: The presence of certain award conditions and/or enforcement actions related to
credentialing and privileging may demonstrate noncompliance with FTCA Program requirements
and may result in disapproval of deemed status.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CLAIMS MANAGEMENT

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

CLAIMS MANAGEMENT
All questions with an * in this sectionfields marked with * are required.
Please note: Health centers are expected to maintain their own records of medical malpractice
claims as part of their risk management systems and in accordance with local practice requirements
and guidelines.
If a claim or lawsuit involving covered activities is presented to the covered entity/individual or filed in
court, it is essential that the covered entity preserve all potentially relevant documents. Once a
covered entity or covered individual reasonably anticipates litigation—and it is reasonable to
anticipate litigation once a claim or lawsuit is filed, whether administratively or in state or federal
district court—the entity or individual must suspend any routine destruction and hold any documents
relating to the claimant or plaintiff so as to ensure their preservation for purposes of claim disposition
or litigation.

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1(A). **I attest that my health center has a claims management process for addressing any potential
or actual health or health-related claims, including medical malpractice claims, thatwhich may be
eligible for FTCA coverage. My health center’s claims management process includes information
related to how my health center ensures the following:
a.i.
The preservation of all health center documentation related to any actual or potential
claim or complaint (for examplee.g., medical records and associated laboratory and xray results, billing records, employment records of all involved clinical providers, clinic
operating procedures); and
b.ii.
That any service of process/summons that the health center or its provider(s) receives
relating to any alleged claim or complaint is promptly sent to the HHS, Office of the
General Counsel, General Law Division, per the process prescribed by HHS and as
further described in the FTCA Health Center Policy Manual.

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Yes [ ] No [ ]
If “No”, provide an explanation.
[2,000 character comment box]
1(B). *I also acknowledge and agree that failure to implement and maintain a claims management
process as described above may result in disapproval of this deeming application.
Yes [ ] No [ ]
If “No”, provide please enter an explanation.
[2,000 character comment box]
1(C). *Upload documentation of the health center’s claims management process (for example, claims
management procedures) for addressing any potential or actual health or health-related claims,
including medical malpractice claims, that may be eligible for FTCA coverage. In addition, this process
includes the items outlined in Claims Management question 1(A).a-b of this application.
[Attachment control named ‘Claims Management Procedures’] (If answer to 1(A) is Yes,
attachment required; if answer to 1(A) is No, no attachment is required.)
2.
2(A). **Has the health center had any history of claims under the FTCA? (Health centers should Formatted:
provide any medical malpractice claims or allegations that have been presented during the past 5
years.)

No bullets or numbering

Yes [ ] No [ ]
•

If Yes, uUpload a list of the claims. For each claim, include:
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CLAIMS MANAGEMENT

a.i.
b.ii.
c.iii.
d.iv.
e.v.
f.vi.
g.vii.

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

CLAIMS MANAGEMENT
All questions with an * in this sectionfields marked with * are required.
Name of provider(s) involved;
Area of practice/Specialty;
Date of occurrence;
Summary of allegations;
Status or outcome of claim;
Documentation that the health center cooperated with the Attorney General for this
claim, as further described in the FTCA Health Center Policy Manual; and
Summary of health center internal analysis and implemented steps to mitigate the risk
of such claims in the future (OPlease only submit a summary if the case is closed. If
the case has not been settled do not include the summary. Do not submit a copy of
the NPDB report in this section.).

[Attachment control namcalled ‘History of Claims’]
2(B). *I agree attest that the health center have, will, and must cooperate with all FTCA division
officials, Health and Human Services officials, Department of Justice officials, and any other applicable
Federal government representatives in the defense of any FTCA claims and understand that failure to
do so may result in the disapproval of this FTCA application and future FTCA applications.

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Yes [ ] No [ ]
If “No”, provide an explanation.
[2,000 character comment box]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CLAIMS MANAGEMENT

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

CLAIMS MANAGEMENT
All questions with an * in this sectionfields marked with * are required.
3(A). **I attest that my health center informs patients using plain language that it is a deemed
fFederal Public Health ServicePHS employee via its website, promotional materials, and/or within an
area(s) of the health center that are is visible to patients. For example: “This health center receives
HHS funding and has fFFederal Public Health Service (PHS) deemed status with respect to certain
health or health-related claims, including medical malpractice claims, for itself and its covered
individuals.”
[ ] Yes [ ]No
If No, provide please enter an explanation.
[2,000 character comment box]
3(B). IPlease include a link to the exact location where this information is posted on your health center
website, or please attach the relevant promotional material or pictures.
[Free Response Control to type in link]
[Attachment control named ‘FTCA Promotional Materials’]
(If answer to 3(A) is Yes, either free response control or attachment required; if answer to
3(A) is No, no free response control or attachment is required.)
3(C). *Upload the relevant Position Description(s) that describe the health center’s designated
individual(s) who is responsible for the management and processing of claims- related activities and
serves as the claims point of contact. The job description must clearly detail that the claims
management activities are a part of the individual’s daily responsibilities.
[Attachment control named ‘Claims Management Position Descriptions’]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

ADDITIONAL INFORMATION

FOR HRSA USE ONLY
GranteeAward Recipient
Name

Application Type

Application Tracking
Number

Grant Number

CERTIFICATION AND SIGNATURES
Completion of this section by a typed name will constitute signature on this application.
This field is required.
*I[
] declare under the penalty of perjury that all statements contained in this application
and any accompanying documents are true and correct, with full knowledge that all statements
made in this application are subject to investigation and that any material false statement or
omission in response to any question may result in denial or subsequent revocation of coverage.
I understand that by printing my name I am signing this application.
Please note – this must be signed by the Executive Director, as indicated in the Contact Information
Section of the FTCA application. If not signed by the Executive Director, the application will be
returned to the health center.

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