Organ Procurement and Transplantation Network Application

Department of Health and Human Services OMB No. 0915-0184

Health Resources and Services Administration Expiration Date: ______

APPLICATION FOR APPROVAL OF A

CLINICAL TRANSPLANT PROGRAM

IN AN EXISTING MEMBER TRANSPLANT HOSPITAL

ORGAN PROCUREMENT AND TRANSPLANTATION

NETWORK (OPTN)

UNOS

700 North 4^th 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 hospital, 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: ______________________________________________

Member Code: _______________

Print Title: _______________________________________________

Applicant for Clinical Transplant Program

Instructions

1. A Clinical Transplant Program applicant must have previously completed the General portion of the OPTN Application for Institutional Membership. For the purposes of applying for additional transplant programs, an organ specific application must be completed for each program. Criteria for Institutional Membership are found in the Bylaws.

Transplant programs are:

A. Kidney (including Living Donor Kidney) E. Pancreas

B. Heart F. Lung

C. Heart/Lung H. Islet Cell

D. Liver (including Living Donor Liver)

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 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 http://optn.transplant.hrsa.gov .

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

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. Do not omit pages that were not used.

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 OPTN requirements. Documentation may be blinded in such a way as to protect patient confidentiality. Check lists 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.

7. Applications must be typed and complete.

8. Materials should be loose bound with tabs. Originals and copy should be organized in the following sequence:

1) Signed Cover/Certification page

2) General Section

3) Organ Specific Application(s)

4) Signed Program Coverage Plan(s) – one must be submitted for each organ-specific application

5) OPO letter of agreement or new contract

6) Documentation of Medicare/Medicaid certification for this program, if applicable (excluding pancreas.)

7) Letters from Hospital Credentialing Committee

8) Letters of Commitment

9) Letters of Reference

10) 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. Please use a separate log for each institution.

11) CVs (individual CVs must be stapled in the original and copy). Abbreviated CVs that do not include publications and presentations are preferred.

12) Cumulative Recipient log (Islet only)

13) Allocation Report (Islet only)

9. Return the original and one (1) complete paper copy of all application materials to the address listed below.

Express Mail US Mail

UNOS UNOS

Membership Services Membership Services

700 North 4^th Street P.O. Box 2484

Richmond, VA 23219 Richmond, VA 23218

Main Phone: 804-782-4800

12/01/2010 version