SECTION I - APPLICANT INFORMATION

APPLICATION TYPE
(Please check one)

GRANTEE NAME:                                 [GRANTEE NAME]

DBA Name (if appropriate):                    [DBA NAME]

UDS #:       [UDS#]                                                                    GRANT #:         [GRANTEE #]

Check all that apply:

ADDRESS:                                          
[ADDRESS]

TELEPHONE:    [TELEPHONE]

SUB-RECIPIENTS APPLICATIONS INCLUDED (if appropriate):
Grantees should indicate the name(s) of their sub-recipient(s) (as documented on FORM 5B)

1.                                                                                                                   

2.                                                                                                                    

3.                                                                                                                    

EXECUTIVE DIRECTOR NAME:                         [EXECUTIVE DIRECTOR NAME]

Email:

Telephone: [EXECUTIVE DIRECTOR TELEPHONE]

MEDICAL DIRECTOR NAME:

Email:

Telephone:

RISK MANAGER NAME:

Email:

Telephone:

DEEMING CONTACT NAME:
(Individual responsible for completing application)

Email:

Telephone Number:

SECTION II – REVIEW OF RISK MANAGEMENT SYSTEMS (Section 224(h)(1)

Indicate Yes or NO to the following statements.
NO responses require explanation on a separate sheet.

YES

NO

The organization conducts periodic assessments to identify, prevent and monitor medical malpractice risk. 

There are policies/procedures on the appropriate supervision and back-up of clinical and non-clinical staff.

A medical record is maintained for every patient of the health center.

There are policies/procedures that address triage, walk-in patients, and telephone triage.

There are clinical protocols that define appropriate treatment and diagnostic procedures for selected medical conditions.

There is a tracking system for patients who require follow-up of specialty referrals, hospitalization, x-ray, and lab results.

Medical records are periodically reviewed to determine quality, completeness, and legibility.

Quality improvement/assurance findings are used to modify policies/procedures in order to improve quality of care.

There is a written Quality Improvement/Assurance Plan (QI/QA Plan) approved by the governing board.

If yes, attach a current copy of the QI/QA plan and include the approval date. 
NOTE: To help ensure confidentiality, please DO NOT submit actual agendas or minutes.

For deeming purposes, the QI/QA Plan must include or describe the following elements under Sections 330(k)(3)(C) and 224(h) of the PHS Act and 42 CFR 51c.303(c)(1-2):

• There is a clear focus of responsibility to support the quality assurance/ improvement program and the provision of high quality patient care.

• There is a periodic assessment of the appropriateness and quality of the services provided, or proposed to be provided, to individuals served by the applicant.

• Assessments are conducted by physicians or by other licensed health professionals under the supervision of physicians; based on the systematic collection and evaluation of patient records; and identify and document the necessity for change in the provision of services by the applicant and result in the institution of such change, where indicated.

SECTION III – REVIEW OF CREDENTIALING SYSTEMS (Section 224(h)(2)) 

Indicate YES or NO to the following statements. 
NO responses require explanation on a separate sheet.

YES

NO

All health care personnel involved in direct patient care are credentialed at least every two years, including all of the following:

• licensed independent practitioners (e.g., physicians, nurse midwives, nurse practitioners);
• licensed practitioners (e.g., RNs, LPNs);
• certified practitioners/technicians (e.g., dental, lab, radiology)

The health center’s credentialing verification procedures include all of the following:

• current licensure, professional certification, and/or registration that is primary source verified
• professional educational background/postgraduate training
• primary source verified for licensed independent practitioners
• secondary source verified for licensed and certified practitioners

As part of the health center’s credentialing process, each practitioner is required to submit evidence of each of the following for review including  all of the following:

• health fitness/fitness to perform duties
• immunization status
• professional references
• certification in life support, as applicable
• DEA registration, as applicable

A National Practitioner Data Bank query is obtained and evaluated for each licensed practitioner as part of the health center’s credentialing process.

A history of previous malpractice liability claims and adverse actions (including FTCA claims) is reviewed for each practitioner and for your organization.

The health center utilizes data from peer review and quality/performance improvement activities to support its credentialing functions, and these activities are overseen by its governing board.

As part of the health center’s privileging process, all of the following occurs:

• practitioners are granted privileges by the health center, at least every two years, specific to the services being provided at each care delivery site; and
• clinical privileges and medical staff membership at local hospitals and other admitting facilities are verified

SECTION IV – REVIEW OF PROFESSIONAL LIABILITY HISTORY (Section 224(h)(3))

Please note: Health centers are expected to maintain their own records of medical malpractice claims as part of their risk management systems.

Initial deeming applicants only.  Please check one:

 ¨No professional liability suits were filed or closed (by settlement or plaintiff verdict) against the health center and/or its employees/contractors over the last 5 years.

 ¨Professional liability suits were filed or closed (by settlement or plaintiff verdict) against the health center and/or its employees/contractors over the last 5 years.

• Applicants must provide a list of all professional liability claims or suits (including FTCA claims where applicable) filed or closed by settlement or plaintiff verdict against the health center and/or its employees/contractors over the last 5 years. Include the date of the complaint, the allegation, current status, and amount of payment, as applicable. 
• The listing should include a brief summary of the actions taken by the health center to analyze these incidents, the corrective actions taken or planned to prevent such claims in the future, and any resulting systems or clinical improvements, as applicable.

Renewal deeming applicants only.  Please check one:

 No professional liability suits were filed or closed (by settlement or plaintiff verdict) against the health center and/or its employees/contractors over the last 5 years.

 Professional liability suits were filed or closed (by settlement or plaintiff verdict) against the health center and/or its employees/contractors over the last 5 years.

- Applicants must provide a list of pending FTCA claims, as well as FTCA claims closed by settlement or plaintiff verdict, over the last five years.  The listing should include a brief summary of the actions taken by the health center to analyze these incidents, the corrective actions taken or planned to prevent such claims in the future, and any resulting systems or clinical improvements, as applicable.

SECTION V – ADDITIONAL INFORMATION

If your health center has achieved one or more of the following

• recognition;
• certification; or
• accreditation

from a national review body by demonstrating the ability to meet nationally recognized standards, guidelines, and measures related to quality assurance and quality improvement in health care organizations.

If your health center’s personnel have participated in risk management training or continuing education within the past year.

SECTION VI - SIGNATURES

Completion of this section through either hand-written or typed name will constitute signature of this application.

EXECUTIVE DIRECTOR NAME