Get Policy Information Notice 2004-24. Policy Information Notice 2004-24 - Bphc Hrsa

The Policy Information Notice 2004-24 serves as a crucial form for free clinics seeking Federal Tort Claims Act (FTCA) coverage for volunteer health care professionals. This guide will provide you with straightforward, step-by-step instructions to effectively complete the form online.

Follow the steps to complete the Policy Information Notice 2004-24.

1. Click the ‘Get Form’ button to obtain the Policy Information Notice 2004-24 and open it in your chosen editor.
2. In Section I, provide the corporate name of the sponsoring free clinic along with the address and contact information for the Chief Executive Officer and Medical Director. Ensure all details are accurate and complete.
3. In Section II, list all free clinic sites where volunteer health care professionals will be providing services, specifying whether each site is a main or additional location.
4. In Section III, verify the credentialing and privileging systems by marking 'Yes' or 'No' for each criterion, providing explanations for any 'No' answers in Section V.
5. In Section IV, assess and confirm the risk management systems by checking 'Yes' or 'No' for each item listed, similarly providing explanations for any 'No' responses.
6. In Section VI, list all volunteer health care professionals that the free clinic wishes to sponsor for FTCA deemed status, including their professional designations, specialties, and contact information.
7. In Section VII, provide a history of all medical malpractice claims against the free clinic and its sponsored volunteers for the last ten years, including any actions taken to prevent such claims.
8. Lastly, in Section VIII, ensure that the signatures of the Chief Executive Officer and Medical Director are obtained, verifying the accuracy and completeness of the application.
9. After completing the form, save any changes, download the form as necessary, and consider printing or sharing it with relevant parties.

Complete the Policy Information Notice 2004-24 online to ensure your free clinic's compliance and coverage.