Form Cms-576 - Organ Procurement Organization (Opo) Request For Designation As An Opo Under 1138 Of The Social Security Act

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Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0512

INSTRUCTIONS FOR COMPLETING ORGAN PROCUREMENT ORGANIzATION (OPO) REQUEST FOR DESIGNATIONS

AS AN OPO UNDER §1138 OF THE SOCIAL SECURITY ACT

STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES

Submission of this form will initiate the process of obtaining a decision as to whether the Conditions for Coverage: OPOs, are met. The form provides

information and data about the OPO that is necessary to determine compliance with the Conditions and provides a data base necessary for responding

to questions frequently asked by Congress, Federal agencies, and interested members of the public.

Answer all questions as of the current date. Return the original form and the signed agreement to the regional office serving your area and make a

copy for your files. Failure to return this form may result in termination for the service area. The name, address and service areas of the regional offices

are attached.

Detailed instructions are given for questions other than those considered self-explanatory.

Item I: Identifying Information

Item IV: Narrative

•

Medicare provider number: Insert the facility’s six digit Provider

Please answer the questions in this section completely and concisely.

Number. Leave blank on initial request for designation.

Failure to do so may hinder consideration. Attach supporting

documentation, such as agreements, statistical data, etc. The

•

State/County and State Regional Codes: Leave blank. The Centers for

documentation should explain the OPO’s plans or systematic efforts to

Medicare & Medicaid Services Regional Office will complete.

provide its organ procurement services. The preferable documentation is a

•

Related provider number: If the OPO is affiliated with any other

copy of the written agreements with the various hospitals and transplant

Medicare provider, insert the related facility’s six digit Medicare

centers in the service area that list the OPO’s responsibilities and functions.

provider number.

If an organization seeking designation as an OPO does not have a written

agreement with a given facility, we will accept a letter of intent from a

Item II: Type of Control

hospital or transplant center that it will enter into such agreement within

Check the category(ies) that is most descriptive of the type of organization

not more than 12 months after the OPO’s designation. If an organization

operating the facility. Check “nonprofit under §501” if the organization is

does not have either a written agreement or letter of intent, it must

exempt from Federal income taxation under §501 or the Internal Revenue

submit other documentation of its working relationship.

Code of 1986.

Item V: Performance

Item III: Administrative and Staffing

Specify the number of actual donors, number of kidneys transplanted,

Give the name and title of members of the Board of Directors, Advisory

number of kidneys recovered, number of extrarenal organs recovered,

Board and staff members.

number of extrarenal organs transplanted and the average number of

organs retrieved per donor. This information is to be submitted 15 days

following the end of each calendar year.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-0512. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review

instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s)

or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-576 (01/93)