CMS-576
Organ Procurement Request for Designation as an OPO
Form CMS-576 is the Organ Procurement Organization (OPO) Request for Designation as an OPO under section 1138 of the Social Security Act, from the Centers for Medicare & Medicaid Services. The form says submitting it starts the process of deciding whether the Conditions for Coverage for OPOs are met, and that its data also helps answer questions from Congress, Federal agencies and the public.
It has five items: identifying information and the service area, type of control, administration and staffing, a narrative with supporting documentation, and performance figures for the 2 calendar years before the year of designation. An authorized official signs it in ink.
The form says to return the original form and the signed agreement to the regional office serving your area and keep a copy. You can fill it out free in your browser on this page and download the result without an account.
Facility name, address, phone, chief executive and provider numbers, plus the service area: the areas served or the State, geographic boundaries, total population, and acute care hospitals with an operating room and the equipment and personnel to retrieve organs.
Check all that apply: independent, hospital-based, individual, profit, corporation, nonprofit under section 501, partnership, Federal government or State government.
Names and titles of Board of Directors and Advisory Board members who represent 11 listed groups, from a hospital administrator and transplant surgeons to members of the public residing in the area.
Twelve questions with supporting documentation, covering hospital working relationships, organ allocation, tissue typing, accounting, potential donors, tissue banks, HIV testing, transplant centers, confidentiality, professional education and hospital protocols.
For two calendar years: actual donors, kidneys transplanted and recovered, extrarenal organs recovered and transplanted, and the average number of organs procured per donor.
The authorized official signs in ink and dates the form, under a warning about false statements and failing to disclose the information requested.
The instructions say to answer all questions as of the current date.
The form asks that the instructions and information collection statement on its cover sheet be read before completing it.
Enter the facility details and describe the service area. A separate sheet can be attached if more space is needed.
Check the type of control and list the board members who represent each group named on the form.
The instructions say the preferable documentation is a copy of the written agreements with hospitals and transplant centers in the service area.
Enter the Item V figures for the 2 calendar years before the year of designation.
Sign in ink, then return the original form and the signed agreement to the regional office serving your area, keeping a copy.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
To the regional office serving your area, according to the form. The form says the regional offices' names, addresses and service areas are attached, but the PDF on the CMS page does not include that list.
The form says failure to return it may result in termination for the service area.
Without a written agreement with a facility, the instructions say a letter of intent from a hospital or transplant center to enter into one within 12 months of designation is accepted. Without either, other documentation of the working relationship is asked for.
The Item V performance information is to be submitted 15 days following the end of each calendar year, the form says.
The form estimates an average of 2 hours per response.
The form is a request from an organ procurement organization for designation as an OPO.
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The form says to return the original form and the signed agreement to the regional office serving your area and make a copy for your files.
No. The instructions say to leave the six digit provider number blank on an initial request for designation.
The instructions say the documentation should explain the OPO's plans or systematic efforts to provide its services, and that the preferable documentation is a copy of the written agreements with hospitals and transplant centers in the service area.
The instructions say a letter of intent to enter into an agreement within 12 months after designation is accepted. Without either, the form asks for other documentation of the working relationship.
The form says the procurement activity is for the 2 calendar years prior to the year of designation.
The authorized official, in ink, with the date.
