OHF Care Center Network Application Load saved progress Checking for saved data... Fields marked with an * are required HTML Facility Information(Required) Main Institution Name (The clinical facility where most patient visits and tests will occur) * Institution Address - Street Name * City * State/Province * Zip/Postal Code * Institution Main Phone Number * Institution Type * Academic Private Please List Affiliated Hospitals and Facilities (if applicable) * Please indicate which of the following specialties your center is able to provide: * Pediatric nephrology Adult nephrology Urology Medical genetics Cardiology Genetic counselors Transplant team Ophthalmology Reproductive medicine Neonatology Radiology/imaging Social workers Registered dietitians/nutrition Please indicate which (if any) of the following support staff your center is able to provide: Research Coordinators Administrative Staff Nurse Coordinators Please add any additional comments regarding service availability Divider HTML Copy Center Director(Required)General Information Please list the Center Director and their specialty (Adult Nephrology, Pediatric Nephrology, or Other) * Please list your office address * Please list your email address * Please list your office number * Please list your mobile phone number * Please list your title and qualifications * Please list your specialty (and sub-specialty if applicable), and academic affiliation * Which (if any) OHF Clinical Center(s) have you visited? When (year)? (If none, please indicate "none".) * Where did you complete post-college training (graduate/medical school, residency, fellowship etc.), and what dates did you attend? * HTML Copy Copy Primary Hyperoxaluria Experience How many primary hyperoxaluria or suspected primary hyperoxaluria patients has you center identified in the past 3 years? * Have you had the opportunity to attend a hyperoxaluria-related conference or lecture at a national or international meeting in the past 5 years? If so, which ones? * Check to assert: "I, the Center Director acknowledge that the information provided above is accurate to the best of my knowledge." * HTML Copy Copy Center Co-DirectorGeneral Information Please list the Center Co-Director and their specialty (Adult Nephrology, Pediatric Nephrology, or Other) Please list their office address Please list their email address Please list their office number Please list their mobile phone number Please list their title and qualifications Please list their specialty (and sub-specialty if applicable), and academic affiliation Which (if any) OHF Clinical Center(s) have they visited? When (year)? (If none, please indicate "none".) Where did their complete post-college training (graduate/medical school, residency, fellowship etc.), and what dates did they attend? HTML Copy Copy Copy Primary Hyperoxaluria Experience How many primary hyperoxaluria or suspected primary hyperoxaluria patients has their center identified in the past 3 years? Have they had the opportunity to attend a hyperoxaluria-related conference or lecture at a national or international meeting in the past 5 years? If so, which ones? Check to assert: "The Center Co-Director acknowledges that the information provided above is accurate to the best of their knowledge." HTML Copy Copy Copy Copy Copy Application to the OHF Care Center Network is voluntary, submission signifying applicants' commitment to engaging in collaborative initiatives with fellow care center members, facilitating sharing valuable information and resources, including via the OHF Registry, and ultimately contributing to the improvement of healthcare practices and the enhancement of patient care in hyperoxaluria. Benefits for accepted members of the Care Center Network include the opportunity for collaboration with other certified centers, access to educational resources, and participation in OHF educational and conference opportunities. Additionally, accepted members will be listed on the OHF website. HTML Copy Copy Copy Copy Copy Copy Supporting DocumentsPlease send any supporting documents to Kimh@ohf.org and note "(Institution Name) OF Care Center Application Supporting Documents" in the subject field. If you are a human seeing this field, please leave it empty.
