TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER f: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 545 SEXUAL ASSAULT SURVIVORS EMERGENCY TREATMENT CODE
SECTION 545.APPENDIX B SEXUAL ASSAULT TRANSFER PLAN FORM

 

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 an 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, 4th Floor

Springfield, Illinois 62761-0001

 

PART A

 

Name of Transfer Hospital:

 

Mailing Address:

 

Contact Person for Program:

 

 

(Name)

(Job Title)

 

(E-mail)

(Telephone Number)

(Fax Number)

Contact Person for Billing:

 

 

(Name)

(Job Title)

 

 

(E-mail)

(Telephone Number)

(Fax Number)

Estimated number of sexual assault survivors to be transferred in coming FY:

 

Name of affiliated Treatment Hospital:

 

Distance of Transfer Hospital from affiliated Treatment Hospital:

 

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

 

 

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

 

 

 

PART B

 

                                   

1.         Describe the procedures that will be taken to ensure privacy and support for the survivor.  Services shall be in accordance with Section 545.65 of the Regulations.

 

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

 

PART C

 

Review and sign the Conditions of Approval:

 

CONDITIONS OF APPROVAL

 

The following conditions of approval shall apply to all hospitals providing transfer services to sexual assault survivors.  These conditions are enumerated below to ensure that all transfer hospitals 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 sexual assault survivors in accordance with Section 545.65 of the Regulations.

 

3.         The hospital shall provide services at no direct charge to the survivor.  If the survivor is neither eligible to receive services under the Illinois Public Aid Code nor covered by a policy of insurance, the hospital shall seek reimbursement only from the Department of Healthcare and Family Services (HFS) according to procedures established by HFS for that purpose (Hospital Services, 89 Ill. Adm. Code 148).

 

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 HFS on properly authenticated vouchers supplied by HFS for all eligible survivors for whom hospital emergency services were provided pursuant to its Transfer Plan.

 

6.         The hospital shall maintain all survivor medical records in a manner and for a duration established by hospital policy 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 33 Ill. Reg. 14588, effective October 9, 2009)