Registration:

Please have the OPTN approved Program Director (surgeon or physician) complete this registration form for your live donor program. The program director will need to provide the names and email addresses of two transplant professionals authorized to file applications to the NLDAC on behalf of your prospective living donors. The program director is also required to attest that your transplant program is in good standing with the OPTN. Check only those organs for which you are the OPTN approved Program Director.


Transplant Center Name:
Living Donor Program: (check all that apply)
Liver Kidney	Lung Intestine

Liver Program
Program Director Name
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #1
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #2
First Name: *	M.I	Last Name: *
Email Address: *
Please list the names and phone numbers of two hotels your transplant program routinely uses for living donors.
Hotel Name #1	Hotel Phone #1
Hotel Name #2	Hotel Phone #2

Kidney Program
Program Director Name
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #1
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #2
First Name: *	M.I	Last Name: *
Email Address: *
Please list the names and phone numbers of two hotels your transplant program routinely uses for living donors.
Hotel Name #1	Hotel Phone #1
Hotel Name #2	Hotel Phone #2

Lung Program
Program Director Name
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #1
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #2
First Name: *	M.I	Last Name: *
Email Address: *
Please list the names and phone numbers of two hotels your transplant program routinely uses for living donors.
Hotel Name #1	Hotel Phone #1
Hotel Name #2	Hotel Phone #2

Intestine Program
Program Director Name
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #1
First Name: *	M.I	Last Name: *
Email Address: *
Name of Designated Application Filer #2
First Name: *	M.I	Last Name: *
Email Address: *
Please list the names and phone numbers of two hotels your transplant program routinely uses for living donors.
Hotel Name #1	Hotel Phone #1
Hotel Name #2	Hotel Phone #2

ATTESTATION OF MEMBERSHIP AND PROFESSIONAL STANDARDS COMMITTEE (MPSC) STANDING
I hereby certify that the transplant program for which reimbursement of living donor expenses is being requested in this registration is in good standing with the Organ Procurement and Transplantation Network (i.e. is not currently considered a Member Not in Good Standing).
Agree Disagree

Potential Donors

If you are considering organ donation, NLDAC may be able to lessen the burden of travel expenses.

More information >

Transplant Centers

Join NLDAC in its mission to reduce financial disincentives to living organ donation.