Section 2800.203  Institutional Information

a)         Narrative description of a multidisciplinary program with prior human experience in the specific proposed procedure(s);

b)         Written protocols for patient evaluation, data collection, and clinical studies included in the program(s);

c)         Institution Review Board (IRB) statement regarding the specific organ transplantation protocol(s);

d)         Description of donor organ retrieval process(es);

e)         Program progress reports and protocol revisions or reaffirmations as these occur;

f)         Submission of the following financial data taken from the last audited "Hospital and Hospital Care Complex Cost Report Certification" FORM HCFA 2552 (Medicare Cost Report) or equivalent information if the applicant is not located in the United States. The cost information is adjusted for inflation using the latest available quarterly reports of Chase Econometrics and Data Resources Incorporated.

1)         Basic Provider Information:  (Worksheet S: S1, Part I and II, S2 Part I and II);

2)         Cost Detail:  Breakdown to Wage (Non-Wage):  (Worksheet A: 46 [Reclassification] and A8 [Adjustment to Expenses], A8-1 [Summary of related organization − provider-based physician costs included in cost report.]);

3)         Cost Detail:  General Service Costs:  (Worksheet B: Part I);

4)         Cost Detail:  Allocation of Capital-Related Costs:  (Worksheet B: Part II);

5)         Cost Allocation:  Statistical Basis:  (Worksheet Bl);

6)         Departmental Cost Distribution:  (Worksheet C: Cl);

7)         Cost Apportionment:  Inpatient, Outpatient, Medical Education:  (Worksheet D: Part I, II and III).

g)         Calculate the following costs using the financial information submitted to the Board:

1)         Regular Room:            $          per day.          

2)         Operating Room:        $          per hour.         

3)         Intensive Care Unit:    $          per day.          

4)         Anesthesiology:          $          per hour.         

5)         Professional Fees:       $          .          

(Source:  Amended at 12 Ill. Reg. 15550, effective September 16, 1988)