2 Application for Deemed Health Center Program Recipients

Application for Deemed Health Center Program Award Recipients to Sponsor Volunteer Health
Professionals (VHPs) for Deemed PHS Employee Status under the Federal Tort Claims Act
(This application is illustrative and the actual application and questions 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 an honorific (Ms., Mrs., Mr.,
Dr., etc.) before the name) All fields marked with an * 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 for purposes of liability protections for those individual VHPs
under section 224(q) of the PHS Act.
[ ] Yes [ ] No
2. The sponsoring health center also acknowledges its understanding that, if its initial entity FTCA
deeming or redeeming application for the applicable calendar year is not approved, its sponsored
volunteers will become ineligible 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 determining whether the entity
is eligible to sponsor health center volunteers for deemed PHS employee status.
[ ] Yes [ ] No

Section I. Sponsoring Health Center Acknowledgments of Deemed Status Requirements
Additional Questions:
1. Since the approval of the sponsoring health center’s most recently submitted and approved
initial entity 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, describe these changes and attach supporting documentation, if applicable.
>> Comment Box [7,000 Characters]
>> Attachment Section (Optional)
2. Are there any conditions on the sponsoring health center’s Health Center 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, 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 health center’s facilities (i.e., at its
approved in scope service sites) or through offsite programs or events carried out by the sponsoring
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

Section II. Volunteer Health Professional: Acknowledgment of Required Performance
Conditions (Responses Required)
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 the 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.):

Section III. Volunteers Sponsored for Deeming
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:
Is this volunteer volunteering solely to administer vaccinations?
[] Yes
[] No
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.]
Note: For volunteers that are solely administering vaccines,
the volunteer agreement should clearly include that
information and should also include any other state or federal
requirements that must be met for the individual to volunteer as a
vaccinator.
Number of Volunteer Hours
Redeeming Applicants Only: How many hours per week did the
volunteer work during the previous coverage period? Previous
coverage year is defined as the most recently passed calendar from
January 1-December 31. This should be the actual number of hours
worked.

Section III. Volunteers Sponsored for Deeming
Credentialing and Privileging
• Date of Last Credentialing:
• Date of Last Privileging:
(Each sponsored VHP must be credentialed and privileged by the
sponsoring health center in accordance with the Health Center Program
Compliance Manual, Chapter 5.) All volunteers must be credentialed at
least every two years.
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.]
Or
For VHPs that are solely administering vaccines, the individual
is operating under a state or federal legislation, declaration,
or exemption that permits the VHP to administer vaccinations
under a special grant of authority.
[ ] Yes

[ ] No

Please upload one of the following:
1) Upload primary source verification of current licensure
and/or certification, or
2) Upload all applicable documentation that demonstrates the
VHP is allowed to provide services under a state or federal
legislation, declaration, or exemption that permits the VHP to
administer vaccinations under a special grant of authority.

Section III. Volunteers Sponsored for Deeming
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, list each claim or action. For each claim or action, input the
following:
• Area of practice/specialty
• Date of occurrence
• Summary of allegations
• Status or outcome of claim or action (Has it been resolved
or settled?) [ ] Yes [ ] No
• Summary of how the sponsoring health center and
sponsored individual volunteer have/will implement
steps to mitigate the risk of such claims or actions in the
future (if FTCA-related, only input a summary if the
case is closed. If the case has not been resolved, indicate
this and do not input the summary).
*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.
I understand that by printing my name I am signing the application.
*The application must be signed by the Executive Director, as indicated in Section I. Contact
Information.