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Department of Health and Human Services
Health Resources and Services Administration

OMB No. Pending
Expiration Date: Pending

APPLICATION FOR INSTITUTIONAL MEMBERSHIP
AS A CLINICAL TRANSPLANT CENTER
IN THE ORGAN PROCUREMENT AND TRANSPLANTATION
NETWORK (OPTN)
United Network for Organ Sharing (UNOS)
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800

Name of Hospital:
Hospital Address:
City, State, & Zip Code:
Contact Person and Title:
Phone: (

)

PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. The OMB control number for this
project is 0915-0184. Public reporting burden for the applicant for this collection of information is estimated to average
45 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland 20857.
CERTIFICATION
The undersigned, a duly authorized representative of the applicant, does hereby certify that the answers and attachments
to this application are true, correct and complete, to the best of his or her knowledge after investigation. By submitting
this application to the OPTN, the applicant agrees: (i) to be bound by the Organ Procurement and Transplantation
Network's (OPTN) rules and requirements, including amendments thereto, if the applicant is granted membership and (ii)
to be bound by the terms, thereof, including amendments thereto, in all matters relating to consideration of the
application without regard to whether or not the applicant is granted membership.
Date:

Signature:

Center Code:

Print Name:
Print Title:

Version date pending

Applicant for Clinical Transplant Center
Instructions
1.

A Clinical Transplant Center applicant must complete the Parts 1-6 that follows these Instructions, including
the organ specific section for each type of transplant program for which it is applying. The Criteria for
Institutional Membership are found in the Bylaws.
Transplant programs are:
A. Kidney (including Living Donor Kidney)
B. Heart
C. Heart/Lung
D. Liver (including Living Donor Liver)

E. Pancreas
F. Lung
H. Islet Cell

Additionally, the Organ Procurement and Histocompatibility Sections will need to be completed.
2.

By submitting this application to the OPTN, the applicant acknowledges that its duly authorized representatives
have received and read the current Charter, Bylaws, and Policies of the OPTN and the applicant agrees: (i) to
be bound by the terms thereof, including amendments thereto, if the applicant is granted membership and (ii) to
be bound by the terms, thereof, including amendments thereto, in all matters relating to consideration of the
application without regard to whether or not the applicant is granted membership. The Criteria for Institutional
Membership are found in the Bylaws which can be accessed on the OPTN website at www.optn.org.

3.

A duly authorized representative of the applicant must review the answers and attachments to the Application,
perform sufficient investigation to determine accuracy and completeness, and sign and date the Certification on
the cover page of the Application. Failure to furnish accurate and complete information in connection with the
Application and requests for supplemental information constitutes grounds for denial or suspension of OPTN
membership. (Authorized representatives include hospital CEO or President. Individuals whose credentials
are being submitted should not sign the application).

4.

Attach additional pages as necessary and reference the question and page number on each attachment. Expand
table rows as needed to fully answer questions.

5.

Answer all questions in full and do not use both sides of the page. "See C.V." or “See Logs” is not an
acceptable answer.

6.

Supporting documentation such as C.V.’s, letters of support, letters of commitment, and patient logs, should be
included as requested to document compliance with the requirements. Documentation may be blinded in such a
way as to protect patient confidentiality.

7.

Application responses must be typed and complete. Do not omit pages that were not used. Electronic versions
(WORD) of this application are available upon request. The Membership and Professional Standards
Committee (MPSC) may not accept for review applications that are not appropriately completed and that are
missing the supporting documents for the proposed primary individual(s). Applications determined to be
incomplete may be returned to the institution.

Version date pending

8.

Each set (original and copy) should be loose bound with tabs. Original and copy should be organized in the
following sequence:
1) Cover and General Section
2) Organ Specific Application(s)
3) OPO Section
4) Lab Section
5) Documentation of Medicare/Medicaid certification (if applicable)
6) Letters from Hospital Credentialing Committee
7) Letters of Commitment
8) Letters of Reference
9) Logs of transplant and procurement procedures (and living donor hepatectomies/nephrectomies as
applicable) for the primary surgeon(s) and patient logs for the primary physician. Title each log with
surgeon/physician name, date range, and hospital where the experience occurred as shown in the attached
Tables. Please use a separate log for each institution.
10) CV’s (individual CV’s must be stapled in the original and hardcopy). Abbreviated CV’s that do not
include publications and presentations are preferred.
11) Cumulative Recipient log (Islet only)
12) Allocation Report (Islet only)

9.

Return the original and one (1) complete paper copy of all application materials to UNOS at the address listed
below. Please also return a copy of the application that has been scanned to a CD in PDF format. Label the CD
with the Hospital name, contact name, and date and include an electronic table of contents.
Member Services
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800

Version date pending