Section 545

Section 545.APPENDIX B Sexual Assault Transfer Plan Form

Sexual Assault Transfer Plan

Note: All transfer plans shall conform to the requirements of the federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd).

Instructions: This form describes the minimum components of a Sexual Assault Transfer Plan as part of a community-based or areawide plan. References to the "Regulations" mean the Illinois Department of Public Health Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545). All responses shall be written as clearly and succinctly as possible. If additional sheets are necessary, attach those sheets to the page on which the information is originally requested. A completed copy of the plan shall be retained by the hospital. The completed plan shall be sent to:

Illinois Department of Public Health

Division of Health Care Facilities and Programs

525 West Jefferson Street, 4^th Floor

Springfield, Illinois 62761-0001

PART A

Name of Transfer Hospital:

Mailing Address:

Contact Person for Program:

(Name)

(Job Title)

(Telephone Number)

(Fax Number)

Contact Person for Billing:

(Name)

(Job Title)

(Telephone Number)

(Fax Number)

Estimated number of patients transferred in coming FY:

Name of affiliated Treatment Facility:

Distance of Transfer Hospital from affiliated Treatment Facility:

Estimate of maximum distance patient may have to travel to receive treatment:

Name, telephone number and address of ambulance provider(s):

PART B

1. Describe the geographic area to be covered by the transfer facility, procedures that will be adopted that are compatible with the needs of alleged assault survivors, type of staff available, and steps that will be taken for public education at least annually to ensure that such a program is understood by other medical facilities, police, State's Attorneys, local sexual assault crisis centers, social services agencies, and citizen's groups. The hospital shall formalize transfer arrangements with one or more treatment facilities by contracts, letters of agreement or standard operating procedures as part of a community-based or areawide plan. (See Section 545.65 of the Regulations and attach any jointly-signed agreements to the plan.)

2. Describe the hospital's reasons for electing to provide services to alleged sexual assault survivors as a transfer facility rather than a treatment facility. Factors that should be discussed include accessibility to the community, existing hospital facilities and services, availability and location of nearby treatment facilities, and any other relevant community health planning considerations.

3.. Describe any local ordinances, municipal codes, rules or regulations that apply to the health care or reporting procedures for alleged sexual assault survivors in the hospital's area.

4. Describe the procedures that will be taken to ensure privacy and support for the survivor. Services shall be in accordance with Section 545.65(b), (c), (g) and (i) of the Regulations.

5. Attach a copy of the emergency department treatment record that shall be used as required by Section 545.65(e) of the Regulations.

PART C

Review and sign the Conditions of Approval:

CONDITIONS OF APPROVAL

The following conditions of approval shall apply to all Sexual Assault Emergency Transfer Programs. These conditions are enumerated below to ensure that all transfer facilities are informed and aware of their responsibilities in accordance with the Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545) and the Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70].

1. The hospital shall provide an appropriate medical screening examination and initial stabilizing treatment. (See Section 545.65of the Regulations.)

2. The hospital shall provide pre-transfer and transfer services to alleged sexual assault survivors in accordance with Section 545.65 of the Regulations.

3. The hospital shall provide services at no direct charge to the patient. If the patient is neither eligible to receive such services under the Illinois Public Aid Code nor is covered by a policy of insurance, the hospital shall seek reimbursement only from the Department of Public Aid (IDPA).

4. The hospital shall comply with the Emergency Medical Treatment Act [210 ILCS 70] and the federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd).

5. The hospital shall submit billings to IDPA on properly authenticated vouchers supplied by the IDPA for all eligible patients for whom hospital emergency services were provided pursuant to its Transfer Plan.

6. The hospital shall maintain all patient medical records in a manner and for a duration established by hospital policy and for not less than 10 years, in accordance with Section 6.17 of the Hospital Licensing Act.

7. The hospital shall maintain all business and professional records in accordance with acceptable business and accounting practices, and all records shall be legible. Records shall be retained for a period of not less than three years after the date of service or as required by State law, whichever period is longer, except that if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception is resolved.

	FOR THE HOSPITAL:

	Administrator

(Source: Amended at 27 Ill. Reg. 1567, effective January 15, 2003)