Federal Tort Claims Act (FTCA) and Volunteer Health Practitioner (VHP) Healthcare Professional Volunteer Agreement

This is the VHP health professional (VHP) agreement between FTCA deemed health centers receiving funds under Section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). This VHP Agreement is intended as non-binding guidance to assist health centers and health professionals regarding the VHP’s provision of health services on behalf of the health center.

This agreement is between the VHP identied below and the Free Access Health Clinic, Inc. (FAHC) which is the named health center at 400 Swift Street, Suite 100, South Burlington, Vermont. The parties (VHP and FAHC) to this agreement understand that:

  1. The VHP identified below is a volunteer health professional of the FAHC and is not an employee or contractor of the named health center.
  2. The FAHC sponsors the named VHP for the purpose of receiving deemed PHS employment status, with associated FTCA coverage.
  3. The VHP identied below will not receive any compensation for services rendered, including reimbursement from any third party payor (including reimbursement under any insurance policy or health plan, or under any Federal or State health benefits program).
  4. The VHP may receive repayment from the FAHC for reasonable expenses incurred in providing the service to the patient as allowed by the policies of the FAHC subject to the terms of this agreement.
  5. Before the service is provided, the VHP or the health center will post a clear and conspicuous notice at the site where the service is provided and/ or if provided via telemedicine will provide electronic disclosure that legal liability of the VHP is
    limited.
  6. At the time services are rendered, the VHP will be licensed or certified and in good standing in accordance with applicable federal and state laws.
  7. That the VHP will provide services on behalf of the FAHC and will:
Participate as agreed in providing services covered under this agreement at the FAHC or as permitted via telemedicine and/or at off-site events sponsored by the FAHC.
Participate as agreed in providing services covered under this agreement at the FAHC or as permitted via telemedicine and/or at off-site events sponsored by the FAHC.
Work under the supervision of the FAHC Medical Director, and Executive Director.
Be available to provide role/specialty services (noted below) during the agreed upon days and hours.
Follow the policies, procedures and protocols as required by regulation and the FAHC.

Acknowledged By:

VHP’s Name
Specialty/Job Title Applying for
Phone (Cell)
Date
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