Get Application For Health Center Program Grantees For ... - Hrsa

Filling out the Application For Health Center Program Grantees is essential for ensuring professional liability protection under federal regulations. This guide provides step-by-step instructions tailored to help users navigate the form online effectively, ensuring all required information is accurately submitted.

Follow the steps to complete the form online successfully.

1. Press the ‘Get Form’ button to access the application form and open it for editing.
2. Begin by completing Section I, applicant information. Fill in your grantee name, any Doing Business As (DBA) name, and the UDS number. Select the appropriate category: Community Health, Migrant Health, Health Care for the Homeless, or Public Housing Primary Care, and indicate if you are a sub-recipient.
3. Provide your full address, email address, telephone number, and fax number in the contact information section.
4. List any sub-recipients associated with your application if applicable. Refer to FORM 5B for documentation of these names.
5. Enter the names, emails, and telephone numbers of the executive director, medical director, risk manager, and deeming contact. Ensure that all contact details are accurate.
6. Proceed to Section II and respond to the statements regarding your risk management systems. Indicate ‘Yes’ or ‘No’ for each statement, with a separate explanation required for any ‘No’ responses.
7. In Section III, review the credentialing systems. Again, mark ‘Yes’ or ‘No’ for the statements provided, and be prepared to explain any ‘No’ responses separately.
8. In Section IV, address the professional liability history. Indicate whether there have been any professional liability suits filed in the past five years, and provide the necessary details if applicable.
9. Section V involves confirming if services are provided to non-health center patients. Check all applicable services based on the provided examples.
10. Finally, in Section VI, input the requested effective date of FTCA coverage, and have the executive director and medical director sign the form with the corresponding dates.
11. Review all the filled sections for accuracy and completeness. You can now save your changes, download, print, or share the completed application form as needed.

Complete your application online today to ensure your health center's protection under the Federal Tort Claims Act.