1 T FTCA VHP Application tracked changes

Application for Deemed Health Center Program Award Recipients to Sponsor Volunteer Health Professionals (VHPs) for Deemed PHS Employment

(This application is illustrative and the actual application may appear differently in HRSA’s Electronic Handbooks (EHBs) System)

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

CONTACT INFORMATION (Include a title (Ms., Mrs., Mr., Dr., etc.) before the name) All the fields marked with * are required.
EXECUTIVE DIRECTOR (Must electronically sign and certify the volunteer health professional sponsorship 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 sponsored volunteers will be eligible for FTCA coverage as 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 and the entity’s Notice of Deeming Action will be utilized by HRSA in determinthat the ingentity is eligible to sponsor health center volunteers for deemed PHS employe statuse.

[ ] 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. Are there any conditions on the health center’s program award in the areas of credentialing and privileging and quality improvement/quality assurance?

(Note that unresolved Health Center Program funding conditions in the areas of credentialing and privileging and or QI/QA may demonstrate noncompliance with FTCA Program requirements and may result in disapproval of deemed status for the VHP(s) listed in this application. Also note that HRSA may independently verify this information through review of agency records.)

[ ] Yes [ ] No

If Yes, please explain

>> Comment Box [ 2,000 Characters]

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

(Responses Required)

For each of the individual VHP listed in Section III below, the sponsoring health center acknowledges its understanding that, for a volunteer to be considered a VHP, the following requirements must be met:

1. The services provided by the VHP occur at the sponsoring deemed health center’s facilities (i.e. at its approved service sites) or through offsite programs or events is carried out by the sponsoring deemed health center (section 224(q)(2)(A)).

[ ] Yes

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

[ ] Yes

3. Before the service is provided, the VHP or the sponsoring deemed health center posts 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)(2)(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)(2)(E)).

[ ] Yes

5. The sponsoring health center maintains all relevant documentation certifying that the volunteer meets the requirements to be considered a VHP (section 224(q)2)(F)).

[ ] Yes

The sponsoring health center acknowledges its understanding that for each VHP the following is required:

6. Before the service is provided, the sponsoring health center must credential and privilege the VHP(s) in accordance with all current Health Center Program and FTCA Program credentialing and privileging requirements and maintain this information in a file for each VHP (section 224(q)(3)).

[ ] Yes

Section III. Volunteers Sponsored for Deeming
For each Volunteer Health Professional sponsored for deeming, provide the following information. (Note 1: Do NOT include on this listing individuals who are not volunteer health professionals, such as employees, contractors, governing board members and officers.) (Note 2: Do NOT include on this listing individuals who are trainees (i.e. students, interns, or residents) conducting duties as part of a residency program. These individuals are not eligible for deemed PHS employment through the VHP Program.)
Add Individual Details* Prefix: First Name: Middle Name: Last Name: Professional Designation (e.g., MD, RN, etc.):
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: [Upload a signed volunteer agreement for each individually named volunteer that clearly states that the sponsored health professional is a volunteer of the health center, outlines the terms and conditions of the services that the volunteer will provide, acknowledges that the health professional will not receive any compensation including reimbursement from any third party payor, and documents each off-site program or event where the health professional will provide services.]
Credentialing and Privileging Date of Last Credentialing: Date of Last Privileging: (Each sponsored VHP must be credentialed and privileged by the health center in accordance with the Health Center Program Compliance Manual, Chapter 5.)
Licensure and/or Certification Each sponsored VHP is required to be licensed or certified in accordance with applicable Federal and State laws to perform the services that are requested. [Note: If the answer is No, this volunteer is not eligible for coverage under the Health Center Volunteer Health Professional Program and should not be included in this application.] [ ] Yes [ ] No [Upload primary source verification of current licensure and/or certification. (upload attachment)]
Medical Malpractice History Does the sponsored VHP have any history of state board disciplinary actions and/or state or federal court (including any FTCA) malpractice claims within ten (10) years prior to the submission of this FTCA volunteer health professional deeming application? Include both pending and resolved administrative and civil claims. [ ] Yes [ ] No If yes, provide a list of the claims or actions. For each claim or action, include: Area of practice/specialty Date of occurrence Summary of allegations Status or outcome of claim or action Summary of how the sponsoring health center and sponsored individual have/will implement steps to mitigate the risk of such claims or actions in the future (if FTCA-related, only submit a summary if the case is closed. If the case has not been resolved, indicate this and do not include the summary). (upload attachment)
*Notes: Within the EHBs, the sponsoring health center is required to submit the information outlined above for each individual volunteer for whom it is seeking FTCA coverage. The sponsoring health center must provide both work and personal contact information for each health center VHP the health center is sponsoring for FTCA deemed status.

Section IV. 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.