Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

APPENDIX A

FREE CLINICS FTCA PROGRAM APPLICATION

The following tables provide the information that will be collected in the initial, redeeming, and supplemental deeming sponsorshipsapplication through the :sEHB

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:

Public Burden Statement:  . paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 

.Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free Clinics FTCA Program Policy HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h

. Program Policy Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free Clinics FTCA HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h 

Free Clinics FTCA Program HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h 

 HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h

[ ] 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 HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h

,Free Clinics FTCA Program Policy Guide HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h

freeclinicsftca@hrsa.gov. HYPERLINK "mailto:freeclinicsftca@hrsa.gov" \h

 HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h Free HYPERLINK "https://bphc.hrsa.gov/ftca/freeclinics/policies.html" \h 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.