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SERVIZIO SANITARIO REGIONALE
EMILIA-ROMAGNA
Azienda Ospedaliero • Universitaria di Bologna
ALMA MATER STUDIORUM
Policlinico S. Orsola-Malpighi
UNIVERSITÀ DI BOLOGNA
Dipartimento Attività Integrate
Salute della Donna, del Bambino e dell'Adolescente
Unità Operativa Pediatria - Prof. A. Pession
Programma di Oncologia Ematologia e Trapianto
Responsabile
Dott. Arcangelo Prete
tmoped@aosp. bo.il
Dirigenti Medici
Dott.ssa Maria Elena Cantarini
Bologna 31.07.2014
mariaelena. cantarini@aosp.bo.il
Dott.ssa Elena Facchini
elenajacchini@aosp. bo.il
Azienda Ospedaliero - Universitaria di Bologna, Policlinico S.OrsolaMalpighi, agrees to admit Pavlo BUKHANTSOV (23.12.2009), citizen of
Ukraine, for treatment in our hospital on a chargeable basis.
Dott.ssa Fraia Melchionda
fraia.melchionda@aosp. bo.i t
Dott.ssa Giuseppina Paone
giuseppina.paone@aosp.bo. il
The patient is a candidate for stem celi transplantation from an unrelated donor
(UDSCT), subject to a suitable donor being available.
Dott. Roberto Randelli
roberto.rondelli@aosp. bo.il
Dott.ssa Dorella Scarponi
dorella.scarponi@aosp.bo.i t
Medici
Dott. Riccardo Masetti
Dott. Williarn Morello
Dott. Daniele Zarna
Coordinatore Infermieristico
Dott ssa Barbara Martelli
Te!. : 051.6364401
Referente Infermieristico
Sig.ra Roberta Armuzzi
Te!. : 051.6364427
Reparto
Pad. 13 - Piano V
Tel 051.6364688 FAX: 051.6364675
Unità Trapianto
Pad. 13 - Piano V
Te!.: 051.6364490 FAX: 051.6364491
Day Hospital ed Ambulatorio
Pad. 13 - Piano IV
Tel: 051.6363655 FAX: 051.6363400
T el: 051 .6364665 OH Trapianto
Prenotazione prime visite
Te!. : 800884888 (numero verde)
Prenotazioni controlli
Te!.: 051.6363655
Lun-Merc-Giov-Ve n:
dalle ore 13:30 alle ore 16:00
Mar: dalle ore 13:30 alle ore 15:00
Laboratorio
T el.: 051.636 4464
Segreteria
Tel: 051.6364443 FAX: 051346044
Sig.ra Francesca Predieri
francesca.predieri@unibo.il
The estimated treatment (UDSCT) cost is €90,000.00. The costs include HLA
typing of the patient, siblings and parents, pre-transplantation assessment tests,
conditioning, stem celi transplant and post-transplant care, mainly as an outpatient. The total in-patient time included is 60 days and the total time in Italy
included is 6 months post UDSCT. The estimated treatment cost does not
include any subsequent SCT (from an unrelated donor or haploidentical-family
member) which may be required by the patient. If the patient cannot proceed to
SCT after diagnostics and work-up, the actual costs incurred to that date will be
retained by the hospital and the balance will be refunded to the Ukrainian
Ministry of Health. The costs relate only to the primary diagnosis and not to
any unrelated medicai conditions which may require treatment.
The above estimated treatment cost does not include the cost of the donor
search conducted by the Italian Bone Marrow Donor Registry (IBMDR) and
the stem cells acquisition. Under the local regulations, the hospital cannot
invoice the respective costs. According to the agreement between the hospital,
the IBMDR and Lifeline Italia ONLUS, the Italian charity helping Ukrainian
children who need SCT, Lifeline Italia ONLUS will invoice the estimated cost
of the unrelated donor search and the stem cells acquisition (€30,000.00) and
transfer payment to the IBMDR to initiate the donor search and pay for the
stem cells acquisition when a donor is identified. The search for an HLA
suitably matched donor is conducted in the world donor databases. The ultimate
donor cost depends on the number of donors tested and the national registry
which is chosen. If the donor search is activated by our hospital, the SCT will
Portineria
Tel: 051 .636 3648
Unità Operativa Pediatria
Direttore: Prof. Andrea Pesslon
Via Massarenti.11 - 40138 Bologna
T. +39.051.636.4443 - F. +39 051 346 044
andrea .pession@umbo.it
Azienda Ospedaliero - Uni~~ersitaria di Bologna
Via Aibertoni , 15 - 40138 Bologna
T +39.051.636.1111 - F. +39 +39.05 1.636 1202
Cod . F1sc. 92038610371
AZIENDA OSPEDALIERO-UNIVERSITARIA DI BOLOGNA
have to be performed in our hospital - it will not be possible to perform it in another hospital.
The cost is not fixed and can change during the course of treatment. The final cost will depend on the
number of days as an in-patient and the costs of treatment expended by the hospital on the patient's
care.
Ifthe final cost oftreatment is less than the prepaid cost or ifa force-majeur situation occurs (e.g., the
patient dies before the prepaid money is spent on the patient's treatment) the hospital will refund the
balance to the Ukrainian Ministry of Health.
Prepayment of €90,000.00 is required before a visa invitation is issued and the patient can be admitted
to the hospital.
stamp
· Unità Operativa Pediatria
Direttore: Prof. Andrea Pession
Via Massarenti, 11 -40138 Bologna
T. +39.051 .636.4443 - F. +39.051 .346.044
andrea.pess1on@unibo.1t
Azienda Ospedaliero • Universitaria di Bologna
Via Albertoni 15 - 40138 Bologna
T. +39.051 6361111 - F. +39 +39 051 .6361202
Cod . Fisc. 92038610371
Ministry of Health of Ukraine
7, Grushevskogo str., Kyiv, 01601, Ukraine Mi1-ticmepcmeo oxop01m 3Òopoe 'R YKpai'Hu
Date 31.07.2014 .N"!! 2014/46
00012925 .M. Kui'e eyfl. FpymeecbKozo, 7 YKpai'Ha
Invoice
fl!lami:JJCHUU ÒoKy.MeHm UJOÒo eapmocmi fliKyeaHHR
Name and address of Clinic:
Azienda Ospedaliero - Universitaria di Bologna, Policlinico S.Orsola-Malpighi
ViaAlbertoni 15 40138 Bologna - ViaMassarenti Il 40138 Bologna Italia
Ha:1ea ma aòpeca JtiK)lBaJlbHozo 3aKJtaòy
Name ofthe Patient: BUKHANTSOV Pavlo (23.12.2009)
Jlpi36U'Ll/e X60p020
l. BamoTa rrepeKa3Y
Currency ofpmt:
2. 3ara.JinHa cyMa Total sum ofmoney:
3. O~ep)l(yBa"Y:
Beneficiary:
euros
€ 90,000.00
3.1 HaìiMeHyBaHHH Azienda Ospedaliero
- Universitaria di Bologna, Policlinico S.OrsolaMalpighi
Mpec:
Via Albertoni 15 40138 Bologna - Via
Massarenti Il 40138 Bologna Italia
4. Ko~ KpaiHM Country code
IT
5. HoMep paxynicy Account (IBAN):
6. EaHK o~ep)l(yBa"Y:a
IT50U0200802450000003178927
Account with institution:
Bank
6.1 HaiiMeHyBaHIDI: Unicredit
Mpec Bologna,
Via Indipendenza 11
6.2 S.W.I.F.T.
6.3 BLZ or Sort Code
6.4FWorABA
7.EaHK-KopecrroH~eHT
UNCRITM1NU2
--------------------------
Bank-correspondent
7 .l HaiiMeHyBaHIDI Ta a~peca
Name and address
NONE
8. ,[(eTa.Jii rrnaTe)l(y
7.2 S. W .I.F. T.
7.3 BLZ or Sort Code
7.4FWorABA
Treatment of patient (stem cell transplantation from unrelated donar)
( JiiKYBaHHj! rrauj €HTa)
Details ofpayment (treatment ofpatient)
Dr Prete
ARCANGElAO
J, •••
stamp
PRT
60R25
L049~
At:. Oepea 1-enHJniyersitaria o Bologna
u,o,~-----
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.
SERVIZIO SANITARIO REGIONALE
EMILIA-ROMAGNA
Azienda Ospedaliero - Universitaria di Bologna
ALMA MATER STUDIORUM
UNIVERSITÀ DI BOLOGNA
Policlinico S. Orsola-Malpighi
Dipartimento Attività Integrate
Salute della Donna, del Bambino e dell'Adolescente
Unità Operativa Pediatria - Prof. A . Pession
QUOTATION
Quotation number 2014/46
Date: 31/07/2014
Patient name and passport number
Pavlo BUKHANTSOV
Passport No.
Patient date of birth
23.12.2009
Male
4 Narodiiogo Opolcheniya Str, ap. 17, Kiev, Ukraine; +38 067 686
85 92 mother Liubov
Liubov Grom, 06.01.1984
Passport No. EA031870
Acute myeloid leukemia
(MLL+), first early
diag. 31.07.2013
combined (BM + CNS)
relapse, 2nd acute period
Ukrainian Center for Children Oncohematology and Bone-Marrow
Transplantation, OKHMATDET
Dr. Inna Shergina shergina@meta.ua
Azienda Ospedaliero -Universitaria di Bologna, Policlinico
S.Orsola-Malpighi, Policlinico S.Orsola-Malpighi, Via Albertoni
15 40138 Bologna- Via Massarenti 11 40138 Bologna
Dr Prete
Home address/telephone/e mail
Accompanying parent
Diagnosis and remission status
Ukrainian referring hospital
Name/e mail of referring doctor
Name and address ofltalian treating
hospital
Name of Italian treating doctor
Type of treatment
Cost of treatment
Deposit payment required for visa
Unrelated donor stem cell transplant (UDSCT)
Euros € 90,000.00. The cost relates to the provision ofUDSCT,
including Euros €5,000.00 for HLA typing but excluding donor
costs. Any other treatment not related to the SCT may be extra.
Euros € 90,000.00
Unicredit Bank
IB~IT50U0200802450000003178927
Italian hospital bank account
SWIFT. UNCRITMINU2
Bologna, Via Indipendenza Il
(quote reference 2014/46 Bukhantsov on the payment)
Signed on behalf ofPOLICLINICO
S.ORSOLA-MALPIGHI
stamp
Name:
A-,1...cA rtct ~ ta
/~~
~
ru~ \1,D .f YJ
r
.
..
'.
c•.uYII 1\
~NG soRis •J)t! IW
Al Osoedaliero-Universi1lria d Boli IJII
Payment terms for SCT: ifthe payee is the Ukraini~Ministlj of Health then the Hu~1al payment of the
deposit creates a binding legai agreement to pay the balance of costs. For all other payees payment in full
must be made before the patient travels to Italy.
...l
Cost: if the cost of treatment is less than the quotation, or if the treatment cannot be completed for any
reason, the difference will be refunded to the Ukraine Ministry of Health, or other person/body which has
p ai d.
Informed consent: The patient (if > 16 years) or parents (if <16 years) must sign an informed consent before
HLA typing is performed or a donor search is activated. Unless otherwise agreed in writing leukaemia
patients must be in complete remission before departure from Ukraine.
Lifeline Italia ONLUS
Via Marcanova 6, 35137 Padova, Italia
info@lifelineitalia.org www.lifelineitalia.org
QUOTATION
Quotation number 2014/46LI
Date: 31/07/2014
Patient name and passport number
Pavlo BUKHANTSOV
Passport No.
Patient date of birth
23.12.2009
Male
4 Narodnogo Opolcheniya Str, ap. 17, Kiev, Ukraine; +38 067 686
85 92 mother Liubov
Liubov Grom, 06.01.1984
Liubov Grom, 06.01.1984
Acute myeloid leukemia
Acute myeloid leukemia (MLL+),
(MLL+'), first early
first early combined (BM + CNS)
combined (BM + CNS)
relapse, 2nd acute period
relapse, 2nd acute period
Ukrainian Center for Children Oncohematology and Bone-Marrow
Transplantation, OKHMATDET
Dr. Inna Shergina shergina@meta.ua
Azienda Ospedaliero- Universitaria di Bologna, Policlinico
S.Orsola-Malpighi, Via Albertoni 15 40138 Bologna- Via
Massarenti 11 40138 Bologna
Dr Prete
Unrelated donar search and stem cell procurement for unrelated
donar stem cell transplant
EUR €30,000.00. The final donar search costs depend on how
many donors have to be tested for confirmation. If more than
EUR€30,000.00, the extra will be payable; if less, money will be
refunded.
Home address/telephone/e mail
Accompanying parent
Diagnosis and remission status
Ukrainian referring hospital
Name/e mail of referring doctor
Name and address of ltalian treating
hospital
Name of ltalian treating doctor
Type of treatment
Donar costs
Deposit required to initiate the donar
search
Lifeline Italia bank account
Signed on behalf of Li feline Italia
EUR €30,000.00
Account: Lifeline Italia ONLUS
Bank: Monte dei Paschi di Siena, Padova, ltaly
IBAN: IT61 U 01030 12115 000000137311
BIC: PASCITM126P
(quote reference 2014/46LI Bukhantsov on the payment)
<f~~~~ ~
LlrE:&.JNt: Il AUA
Name: Patrizia Drago
ONLUS
Via Marcanova, 6-35137 PADOVA
stamp
C.F. 92163680282
Payment terms for SCT: payment in full must be made before the patient travels to ltaly.
Cost: if the cost of treatment is less than the quotati an, or if the treatment cannot be completed for any
reason, the difference will be refunded.
Informed consent: The patient (if> 16 years) or parents (if <16 years) must sign an. informed consent before
HLA typing is performed or a donar search is activated.