Small Intestine Candidate Summary Form

Instructions for submitting candidate clinical reviews to the OSOTC:

1. The organ-specific clinical candidate summary form must be filled out by (and will only be accepted from) the transplanting center.

 

2. The clinic summary must be typed, accurate, and filled out in its entirety. Do not state “see attached” on the clinic summary as most unauthorized attachments to the clinical form will not be accepted. The following information must be included in your clinic summary:
   • Adequate medical history
   • Complete lab data as designated on the form
   • A thorough psychosocial evaluation including the patient's support system, any psychosocial issues, attitude toward and understanding of transplant, and informed consent as well as a chemical dependency history, if appropriate.

 

3. On your fax cover, please make certain that you have included contact information for a member of your transplant team who can be responsible for answering any questions that might arise regarding your patient during the review process.

 

4. Once the form is completed, it should be faxed to the Consortium office at 614-436-4449.

 

5. The Consortium office will notify you once the review has been completed.

Comment for non-Ohio transplant centers seeking OSOTC approval for Ohio Medicaid purposes:

1. Please note that Consortium approval is not required when the patient’s primary insurer is Medicare.