Section 2800.202  Patient Information

a)         The following patient medical information is required:

1)         A diagnosis of the condition requiring the proposed transplantation with copies of all tests and applicable workups necessary to support this conclusion (Section 4(b) of the Act.)

2)         A prognosis with and without the transplantation;

3)         A description of the proposed experimental transplantation procedure;

4)         An explanation of the urgency of the transplantation procedure;

5)         The donor organ retrieval plan (only if it is not identical to the plan submitted as part of the institutional information under Section 2800.203(d));

6)         The patient's past and present medical history including prior hospitalizations;

7)         Identification of the patient's medical and surgical physician(s);

8)         Psychosociological evaluation of the patient, (i.e., an evaluation of the patient's family support system, ability to comply with medical care and history of drug and alcohol use);

9)         A statement signed by the patient and/or the patient's parent or guardian authorizing the release of all medical records and information to the Experimental Organ Transplantation Procedures Board and staff.

10)         Certification by the applicant institution that the patient is an appropriate candidate for an organ transplant procedure at that institution and has been medically approved by their medical specialist in this field for this procedure. (Section 4(b) of the Act.)

11)         A statement signed and notarized by the institution certifying that the patient was legally domiciled in Illinois when the pathophysiological state necessitating the organ transplantation procedure was determined and the patient continues to be legally domiciled in Illinois. (See Section 2800. Appendix A) (Section 4(b) of the Act.)

b)         The following patient financial information is required:

1)         Patient identification information (i.e., name, legal address, social security number, date of birth, place of birth, and name of guardian and/or closet relatives);

2)         Documentation and explanation of all accident and health insurance coverage held by the patient;

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