4 Application for Free Clinics to Sponsor Individuals for

FREE CLINICS FTCA PROGRAM APPLICATION
The following tables provide the information that will be collected in the initial, redeeming,
and supplemental deeming sponsorship applications through the EHBs:
(This application is illustrative and the actual application may appear differently in
HRSA’s Electronic Handbooks (EHBs) System)
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:
*Upload state documentation indicating legal name change if legal name change occurred since
last deeming sponsorship application.
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●
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Name:
Address:
Phone Number:
Fax Number:
E-mail:
Site Type:
Days/Hours of Operations:

Section II. Site Information

Section II. Site Information
*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. (Required for initial and redeeming applicants). The sponsoring free clinic is a registered
nonprofit organization. Please attach nonprofit documentation.
Note: The sponsoring free clinic must be clearly identified on the submitted documentation. If
the documents do not align with the name on the application, you must provide updated
documents.
Attachment Control (Attachment A. Non-Profit Documentation (Maximum 5))
[ ] Yes
2. The sponsoring free clinic and its sponsored individuals comply with the definitions
relative to covered individuals (employees, contractors, volunteer health professionals, and
board member and officers) as set forth in section III, “Covered
Individuals”, of the Free Clinics FTCA Program Policy Guide.
[ ] Yes
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
4. The free clinic does not impose charges on patients either based on service provided or the
ability to pay. (The free clinic may accept only volunteer donations from patients and other
third parties.)
[ ] Yes
5. The free clinic is licensed or certified in accordance with applicable law regarding
the provision of health services.
[ ] Yes
[ ] No (If no, then explain)
6. The free clinic and/or individual health professional provides each patient with a written
notification explaining that the legal liability of the deemed individual is limited pursuant to
section 224(o) of the Public Health Service Act, 42 U.S.C. 233(o).
[ ] Yes
Section IV. Credentialing and Privileging Systems*
*This section is required for all initial deeming and redeeming sponsorship applications.
This section is required for supplemental deeming sponsorship applications if the free clinic
has changed its credentialing and privileging system since the annual deeming or initial
sponsorship application.
1. The free clinic verifies licensure, certification, and/or registration of each licensed
and/or certified individual according to the instructions in the Free Clinics FTCA Program
Policy Guide. (Please remember all volunteer health professionals must be licensed or
certified to be eligible for deeming.)
[ ] Yes

2. The free clinic has a copy of the current license, certification, and/or registration on file at
the free clinic for each licensed and/or certified individual. (Please remember all volunteer
health professionals must be licensed or certified to be eligible for deeming.)
[ ] Yes
Section IV. Credentialing and Privileging Systems*
3. If the free clinic contracts with a Credentialing Verification Organization (CVO) for CVO
services, there is a written contractual agreement stating the specifics of these services.
[ ] Yes
[ ] N/A
4. The free clinic utilizes peer review activities when it privileges each licensed and/or
certified individual according to the instructions in the Free Clinics FTCA Program Policy
Guide.
[ ] Yes
5. The free clinic annually reviews any history of prior and current medical malpractice claims
for each individual for whom deeming is sought.
[ ] Yes
6. A National Practitioner Data Bank (NPDB) query is obtained and evaluated on a
recurring basis (for example, every two years) for each licensed and/or certified
individual according to the instructions in the Free Clinics FTCA Program Policy Guide. Note: do
NOT submit a copy of the NPDB report for any individual to HRSA.
[ ] Yes
7. 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.
Section V. Risk Management Systems*
1. The free clinic maintains and implements policies and procedures 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 each patient 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
b. Walk-in patients [ ] Yes [ ] No
c. Telephone triage [ ] Yes [ ] No
If No for any of the above, then explain.
4. The free clinic has protocols that identify appropriate treatment and diagnostic
procedures 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, diagnostics (for example, x-rays), or laboratory results.
[ ] Yes
[ ] No (If no, then explain)
6. The free clinic periodically reviews patients’ medical records to verify quality,
completeness, and legibility of written entries.
[ ] Yes
[ ] No (If no, then explain)
7. The free clinic has a written, current QI/QA or Risk Management plan that clearly
addresses the clinic’s credentialing and privileging process and has been signed by a board
authorized representative on a recurring basis (for example, every three (3) years) (please
attach a copy of the plan with documentation of board approval, including date of approval).
[ ] Yes
[ ] No (If no, then explain)
Attach the free clinic’s QI/QA or Risk Management Plan that has been approved, signed, and
dated by a board authorized representative on a recurring basis (for example, every three (3)
years):
• This attachment is required for initial deeming and redeeming sponsorship applications.
This attachment is required for supplemental deeming sponsorship applications if the free
clinic has changed its QI/QA Plan since the annual redeeming sponsorship application.
Attachment Control (Attachment B. Copy of Clinic’s QI/QA or Risk Management Plan (Maximum
1))
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 QI/QA plan.
[ ] Yes (If yes, explain what information and process is utilized by the clinic when updating and
revising the QI/QA 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 FTCA-deemed individuals 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. The free clinic has assured that each individual sponsored for FTCA deemed status has a
copy of the Free Clinics FTCA Program Policy Guide, and that his/her questions
regarding FTCA medical malpractice coverage have been addressed.
[ ] Yes
[ ] No (If no, then explain)

*Required for initial deeming and redeeming sponsorship applications. Required for
supplemental deeming sponsorship applications if the free clinic has changed its QI/QA
Plan since the annual redeeming sponsorship application.
Section VI. Free Clinic Volunteer Health 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:
Is this volunteer a COVID-19 vaccination
volunteer who will be volunteering solely to
administer COVID-19 vaccinations?
[ ] Yes
[ ] No
Roles and Specialty
• Role(s) in Free Clinic:
• Specialty:
• Others:
Please enter how many hours on average the
volunteer will work per month?
Note:
**Redeeming applicants should enter the
average number of hours per month worked
during the previous calendar year.**
**Initial and supplemental applicants should
enter the estimated or anticipated average
number of hours the volunteer plans to work
per month for the year that the application is
submitted.**

Individual Type (select one):
• New Applicant
• Renewal Applicant
Service Type
• Clinical Work activities (Individuals that provide
clinical care or participate in the supervision and
oversight of clinical care)
• Non-Clinical Activities (Individuals who
conduct purely non-clinical or administrative
activities)
• Both Clinical and Non-Clinical (Individuals who
conduct both clinical and nonclinical/administrative activities)
Please select the status of the individual from the
options below:
• Employee
• Individual contractor
• Officer/Governing Board Member
• Licensed or Certified Health Professional
Volunteer

Credentialing and Privileging
• Date of Licensure/Certification Expiration
• Is Licensure/Certification Currently Active?
Yes/No. If No, please stop here. Select N/A if
this individual is not licensed or certified.
• Date of Last Credentialing:
• Date of Last Privileging: [Please remember that all
state licensed and/or certified health professionals
need to be credentialed and privileged on a
recurring basis (for example, every two years). Not
mandatory for ‘Board Members’ and ‘Executive’
role.]
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 COVID-19
vaccines, the individual is operating under a state or
federal legislation, declaration, or exemption that
permits the VHP to administer COVID- 19
vaccinations under a special grant of authority due to
the ongoing COVID-19 pandemic.
[ ] 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 COVID-19 vaccinations
under a special grant of authority due to the
ongoing COVID-19 pandemic.
Medical Malpractice History
• For initial or supplemental applicants: 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 [N/A]

•

[ ] Yes

For redeeming applicants: Does the sponsored
VHP have any history of state board
disciplinary actions and/or state or federal court
(including any FTCA) malpractice claims
within five (5) years prior to the submission of
this FTCA volunteer health professional
deeming application? Include both pending and
resolved administrative and civil claims.
[ ] No [N/A]

If yes, attach a list of the claims or actions (include
probationary actions). For each claim, suit, or
action, include the following details and
explanation:
• 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 volunteer 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).
For disciplinary actions, you must include:
• nature and reason for the
disciplinary action,
• timeframe (where applicable); and
• 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.
Do not submit an NPDB report for any individual.
Attachment Control (Attachment C. Medical
Malpractice Claims and Disciplinary Actions)

Enter Your Comments
• Comments:
(Comments and an attachment with an explanation
of each medical malpractice claim or disciplinary
action are required for individuals where medical
malpractice claims or disciplinary actions are
indicated. Do NOT submit an NPDB report for any
individual.)
*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. Please note that free clinic volunteer health professionals must be
licensed and/or certified by state or federal law to perform the services that are requested. Provide
a physical address for ALL individuals 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 role in the free clinic for any individual the free clinic is sponsoring for FTCA
deemed status. For each individual sponsored for deeming, disclose past medical malpractice
claims or disciplinary actions for the past ten (10) years if submitting an initial or supplemental
deeming sponsorship application or for the past five (5) years for redeeming sponsorship
applications.
• List the professional designation (for example: MD, NP, LPN) for all licensed and/or certified
individuals for any individual the free clinic is sponsoring for FTCA deemed status. If the
individual is not licensed and/or certified and does not have a professional designation, then
enter “N/A” for “not applicable.”
• Attach an explanation of each medical malpractice claim or disciplinary action (to include
probationary actions) including explanations of the suit or 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. Do NOT submit an NPDB report for any individual.
Section VII. Patient Visit Data*
1. Total number of Free Clinics FTCA Program
deemed individuals, (including health
professionals, officers, board members,
employees, or contractors, in the recently
closed calendar year.
2. Total number of Free Clinics FTCA Program
deemed health professionals (including but not
limited to clinical providers, such as doctors,
nurses, medical assistants).
Note: This number should not exceed the
number reported within Section VII, item 1

above, in the recently closed calendar year.
This number should include all individuals
providing clinical services.
3. Total number of patient visits conducted by
Free Clinics FTCA Program deemed providers:
not to exceed the number reported within
Section VII, item 1 above, in the recently
closed calendar year.
*Only required for the annual redeeming sponsorship application.
Section VIII. Attachments
Attachment D. Other supporting Documentation (Maximum 5)
Please attach any other supporting documentation.
Section IX. Remarks
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 Health Center
Program Support Phone: 1-877-464-4772, Option 1 8:00 a.m. to 5:30 p.m. ET, Monday
through Friday (except Federal holidays) or web form: https://hrsa.force.com/support/s/.
[ ] 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 the HRSA/BPHC Free Clinics FTCA
Program Policy Guide 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.