0

Department of Health and Human Services
Health Resources and Services Administration

OMB No. pending
Expiration Date: pending

APPLICATION FOR APPROVAL OF LIVING DONOR LIVER
TRANSPLANTATION
IN AN EXISTING MEMBER TRANSPLANT CENTER APPROVED FOR
LIVER TRANSPLANTATION
ORGAN PROCUREMENT AND TRANSPLANTATION
NETWORK (OPTN)
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
40 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 center, 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: _______________________________________________
Print Name: ______________________________________________

Center Code: _______________
Print Title: _______________________________________________
version date pending

Applicant for Living Donor Liver Transplantation
Instructions
1.

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 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.

2.

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/President and OPTN Representative. Individuals whose credentials are being
submitted should not sign the application.

3.

Applications must be typed. Do not submit 2-sided pages. Do not omit pages that were not used.
Electronic versions (Microsoft Word or Adobe PDF) of this application are available upon request.

4.

Please attach additional pages as necessary and reference the question and page number on each
attachment. Table rows should be expanded as needed to fully respond to questions.

5.

Answer all questions in full and do not use both sides of the page. "See C.V.” and “See Logs” are not
acceptable answers.

6.

CV's should be included for all primary and new personnel listed. Abbreviated CV’s that do not
include publications and presentations are preferred.

7.

Supporting documentation such letters of support, letters of commitment, and patient logs should be
included as requested to document compliance with OPTN requirements. Documentation may be
blinded in such a way as to protect patient confidentiality. Checklists are provided throughout the
application to help applicants compile the documentation that is required. Each item in the checklist
is cross referenced to the application questions.

8.

Materials should be loose bound with tabs. Original and copy should be organized in the following
sequence:
a)
b)
c)
d)
e)
f)
g)

Cover/Certification page
Organ Specific Application
Documentation of Medicare/Medicaid certification for this program
Letters from Hospital Credentialing Committee
Letters of Commitment
Letters of Reference
Logs of transplants, procurements, and major hepatic resections/living donor hepatectomies
for the primary surgeons. Title each log with surgeon name, date range, and hospital where
the experience occurred. Please use a separate log for each institution.
h) Patient logs for the primary physician. Title each log with physician name, date range, and
hospital where the experience occurred. Please use a separate log for each institution.

version date pending

i)

CV’s (individual CV’s must be stapled in the original and hardcopy).

9.

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.

10

The Criteria for Institutional Membership are found in the Bylaws which can be accessed on the
OPTN website at www.optn.org.

11.

Return the original and one (1) complete paper copy of all application materials. Also provide a copy
of the application that has been scanned to a CD in PDF format. Label the CD with the Hospital
name, contact name, date, and include an electronic table of contents.

12.

Completed packets should be shipped as listed below:
Member Services
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800

version date pending