Donor Hospital Registration

OMB No. 0915-0157; Expiration Date: XX/XX/2026

Donor Hospital Registration

If a donor hospital is not listed in UNet^SM, you may request that it be added. Approved institutions are automatically added to the OPO's list. UNOS Membership handles all requests for new transplant centers, OPOs, and labs. This request form is to add non-OPTN/UNOS member hospitals only. Existing OPTN/UNOS transplant centers should be listed on the main donor hospital list.

CMS hospital name: Enter the name of the donor hospital as it is registered with Medicare. This field is required.

DonorNet donor hospital ID: This field is populated automatically by the system.

Provider ID: Enter the provider ID of the donor hospital. This field is required.

Display name: Enter the display name of the donor hospital. This field is required.

Status: Select the hospital status. This field is required.

Active
Inactive

Street address: Enter the street address of the donor hospital. This field is required.

Does this donor hospital need to be an available option when adding a new donor?: If the donor hospital needs to be an available option when adding a new donor, select Yes. If not, select No. This field is required.

City: Enter the city where the donor hospital is located. This field is required.

Trauma level: Select the hospital’s trauma level (level I, II, III, IV or V).

State: Enter the state where the donor hospital is located. This field is required.

Time Zone: Select the time zone of the city where the donor hospital is located. This field is required.

Eastern

Central

Mountain

Pacific

Alaska

Hawaii

Atlantic

ZIP code: Enter the 5-digit ZIP code of the donor hospital. This field is required.

Is Daylight Savings Time observed?: Indicate if daylight savings time is observed in the city where the donor hospital is located. This field is required.

Yes

No

Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. 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 information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

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