FTCA and HIPAA Acknowledgement for New Patients
Notice of Limited Liability of FTCA Deemed Free Clinc Health Care Professionals This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 USC §§ 1346, 2401 (b), 2671-80) provides the exclusive remedy for damage from personal injury, including dealth, resulting from the performance of medical, surgical, dental or related functions by any free clinic health care practitioner who the Department of Health and Human Services has deemed to be an employee of the Public Health service. This FTCA medical malpractice coverage applies to deemed free clinic health care pratitioners who have provided a required or authorized service unter Title XIX of the Social Security Act (i.e., Medicaid program) at a free clinic site or through offiste programs or events carried out by the free clinic (See 42 USC § 233 (a), (o)).The above Federal law and other State and Federal laws including the Federal Volunteer Protection Act of 1997 may cover certain free clinic health care professionals providing health care services to patients at this free clinic.
Health Insurance Portability and Accountability Act
All health care providers are required by law to inform you about how your medical information is exchanged among other health care providers and other health care entities.
By signing this form, you: Acknowledge understanding of the FTCA program. Acknowledge that you have access to information about the HIPAA, available at hrsa.gov. Understand that all information regarding your insurance is true.
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