Form 127 Pediatric Heart and HeartLung Status 1A Extension and Ap

Pediatric Heart and HeartLung Status 1A Extension and Appeal Justification Forms
Fields to be completed by members
Form Section	Field Label	Notes
1A Extension, Appeal, Extension Appeal Status	Form title	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Status	Case number	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Status	Submitted date	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Status	Resolved date	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Status	Status	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Status	Effective	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	Transplant Center	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	Name	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	Date of birth	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	Waitlist ID	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	SSN	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Information	ABO	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Diagnosis	Diagnosis	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	By criteria	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Congenital Heart Disease Diagnosis (Check all that apply)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Other	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Dobutamine	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Dopamine	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Milrinone	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Epinephrine	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Norepinephrine (Levophed)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	IV Nitroglycerin	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Nesiritide (Natrecor)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Nitroprusside (Nipride, Nitropress)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Phenylephrine (Neo-Synephrine)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Vasopressin (Pitressin)	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	Requires assistance of a mechanical circulatory support device	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Criteria	By exception	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Justification Narrative	Justification narrative	Display Only - Cascades from database
1A Extension, Appeal, Extension Appeal Authorization	Transplant physician name
1A Extension, Appeal, Extension Appeal Authorization	Transplant physician NPI
1A Extension, Appeal, Extension Appeal Authorization	Email decision to
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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.