Form Cms-576 - Organ Procurement Organization (Opo) Request For Designation As An Opo Under 1138 Of The Social Security Act Page 3

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PHYSICIAN WITH KNOWLEDGE, EXPERIENCE, OR SKILL IN THE FIELD OF HUMAN HISTOCOMPATIBILITY OR AN INDIVIDUAL WITH A DOCTORATE

DEGREE IN BIOLOGICAL SCIENCE OR WHO HAS KNOWLEDGE, EXPERIENCE, OR SKILLS IN THE FIELD OF HUMAN HISTOCOMPATIBILITY

TRANSPLANT SURGEONS (from each transplant hospital with an agreement in the service area)

III. ADMINISTRATION

AND STAFFING

(continued)

10. MEMBERS WHO REPRESENT THE PUBLIC RESIDING IN THE AREA

11. NEUROSURGEON OR ANOTHER PHYSICIAN WITH KNOWLEDGE OR SKILLS IN THE FIELD OF NEUROLOGY

ANSWER THE FOLLOWING QUESTIONS AND ATTACH SUPPORTING DOCUMENTATION.

Attach documentation of working relationship that exists with facilities of the service area for harvesting organs. Specify percentage of hospitals in

the service area that you have a working relationship with and specify bed capacity of associated hospitals.

Specify allocation plan for donated organs among transplant patients.

Discuss arrangements for tissue typing donated organs.

Discuss and document your accounting procedures and give name and address of accounting firm.

Submit quantifiable data showing service area, population and number of potential donors per year.

Document your affiliation with tissue banks for the retrieval, processing, preservation, storage and distribution of tissues to assure that all usable

tissues from potential donors are obtained.

IV. NARRATIVE

Discuss and document your procedures for testing for HIV reactivity to prevent the acquisition of organs infected with the etiologic agent for

acquired immune deficiency syndrome.

Document your arrangements to coordinate activities with transplant centers in your service area.

Discuss and document your procedures for ensuring the confidentiality of patient records.

10. Discuss and document your activities relating to professional education concerning organ procurement.

11. Document your assistance with hospitals in establishing and implementing protocols for making routine inquires about organ donations by

potential donors.

12. Discuss and document your procedures for allocating organs equitably among transplant patients consistent with OPTN criteria as approved by the

Secretary.

PROCUREMENT ACTIVITY (the activity is for the 2 calendar years prior to the year of designation):

NOTE: THIS INFORMATION MUST BE SUBMITTED 15 DAYS FOLLOWING THE END OF EACH CALENDAR YEAR.

FIRST CALENDAR YEAR

SECOND CALENDAR YEAR

DATE OF CALENDAR YEAR

MM/DD/YY

NUMBER OF ACTUAL DONORS

V. PERFORMANCE

NUMBER OF KIDNEYS TRANSPLANTED

NUMBER OF KIDNEYS RECOVERED

NUMBER OF EXTRARENAL ORGANS RECOVERED

NUMBER OF EXTRARENAL ORGANS TRANSPLANTED

AVERAGE NUMBER OF ORGANS PROCURED PER DONOR

WHOEVER KNOWINGLY OR WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN

ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE, OR WHERE THE ENTITY ALREADY

PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE.

SIGNATURE OF AUTHORIZED OFFICIAL (Sign in ink)

DATE

Form CMS-576 (01/93)