Download Clinical Trials Radiology Support Core Application

VUMC Dept of Radiology and Radiological Sciences
Clinical Trials Radiology Support Core Application
Study Title:
Study Sponsor:
IRB #
FACTr#
Billing plan#
Principal Investigator:
Other Physicians who would order this study:
Study Coordinator:
Phone:
Pager:
Modality: __ CT __ MR __ NM __ US __ PET __ X-RAY __ Specials
Specific Radiologist in Charge:
Written Report of Interpretation is standard. Explain if not needed:
Equipment Requirements:
Software Requirements:
Imaging/Scanning Protocol Requirement (attach copy of protocol):
Does the study require a Technologist to be in charge of study?
____ Yes
____ No
Does study require specific imaging/scanning protocol?
____ Yes
____ No
*Note Our equipment/scanners are continually upgraded to industry state-of-the-art levels, we cannot guarantee software
and hardware versions and equipment manufacturers continuity for the study duration.
Archival Media/Data Transfer Method: ___ FTP ___ CD ___ MOD
Who will provide the archival media (discs)? (Radiology does not do mailings)
How many subjects do you anticipate to be enrolled in the study?
How long will the study last?
Billing Requirements: How will imaging be reimbursed? (Check one):
____ All patients will be standard of care
____ Billing will be patient specific – some standard of care, some billed to a D & H account
____ All patients will be charged to research D & H account
Person completing Request:
Send Radiology research order forms to:
Beginning in August 2015, all administrative support services offered by the Clinical Trials Radiology Support Core will be
associated with fees based on services rendered. Fees will be charged through the Office of Research CORES/iLab system on a
monthly basis.
Please enter the cost center number to be used for support core charges for this study (center number must be setup and
active on the CORES billing system):