Application

2812.4 – Application (Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) The applicant must submit the following information to the CMS RO by the deadline set out in the open competition announcement: • Completed CMS -Form 576A; • Transition plan that includes timelines for all aspects of the transition including, but not limited to: a. Physical location (office); b. Policies for community outreach; c. Coordination with transplant hospitals in the DSA; d. Coordination with donor hospitals in the DSA; e. Coordination with tissue and eye banks in the DSA; f. Constitution of an Advisory Board; g. Governing Body oversight of the successful transition of the DSA; h. Plan for staff retention or additions to ensure adequate and trained staff coverage in the open area; i. Transfer of donor data; j. Name of Medical Officer; k. A plan for prompt response to hospital referrals; and l. Plan for identifying and addressing the unique challenges of the DSA which impact the performance of the OPO.