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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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Free Clinic Application Process

The application process documented on this page is provided as a guide. Please refer to the applicable Program Assistance Letters (PALs) and Program Information Notices (PINs) for specific details.

Initial Deeming Application

Medical malpractice coverage under the Free Clinics FTCA Program does not occur automatically. FTCA coverage requires HRSA approval of an application for deeming of certain eligible individuals from a sponsoring free clinic. Clinics that are submitting an initial deeming application may do so at any time. This application applies to all eligible individuals at a sponsoring free clinic. Completed applications should be submitted using the application included below.  The deeming application is currently in Microsoft Excel and should be submitted in this format. For more information about the application process, please see PAL 2010-11.


Renewal Deeming Application

Free clinics that currently sponsor deemed individuals must reapply on an annual basis for continued FTCA coverage. The annual redeeming application form is the same application used for original applicants. Redeeming applications for CY 2011 were due September 1, 2010. For more information see PAL 2010-11 (above).


Supplemental Deeming Application

During the course of the year, sponsoring free clinics may wish to add additional eligible individuals for FTCA coverage. In order to supplement the free clinic’s list of covered individuals, a supplemental application must be completed and submitted.

Free clinics submitting their initial deeming application including coverage for volunteer health professionals, board members, officers, employees, and/or individual contractors, must submit an application found below along with the necessary attachments specified in PAL 2010-11.

 

Patient Notice of Limited Liability

Sample Patient Notice of Limited Liability for FTCA Deemed Free Clinic Volunteer Health Care Professionals, Board Members, Officers, Employees, and Independent Contractors.

 

General Application Submission Instructions

To streamline FTCA deeming application submission and processing, free clinics should submit an electronic copy of their deeming application, signature page, and any applicable attachments to freeclinicsFTCA@hrsa.gov. Each application should be sent in one (1) email. The email subject line should include the heading “FTCA Deeming Application” and the free clinic’s FTCA number (FC # XXXX). If the email containing an application does not indicate the identifying free clinic number, as well as all required information, the application will not be considered to have been properly submitted. If this is a deeming application for a new organization, include the words “Original Application” in lieu of the free clinic number.

The application form is to be submitted as an Excel file. Please do not submit a printed and scanned version of the application form. In order to provide an efficient review, all individuals should be listed within the application form without hidden fields. Supplemental applications should only contain new names of individuals requested to be added to a sponsoring free clinic.

All Initial, Redeeming, and Supplemental applications require an attachment explaining any and all disciplinary actions and medical malpractice claims alleged against the eligible individuals applying for deeming. This information is required for the past ten (10) years for new applicants and five (5) years for renewal applicants. Please do not attach a report from the National Practitioner Data Bank (NPDB). These reports do not describe the actions taken by the sponsoring free clinic or the applicant in response to the claims. Additionally, an NPDB report may disclose information exceeding the time frame requested.