Radiology Imaging Research PROTOCOL REVIEW Billing and RESEARCH READ Budgeting Form

This form is to be used only for research requests from CHCO Research Institute.


Information submitted through this form will be used by the CU Dept. of Radiology research staff to generate invoices for protocol reviews that are requested by CHCO Research Institute.


Information collected through this form will also be used by the research staff to provide an estimate SPECIALIZED RESEARCH READ for a research study that is ABOVE AND BEYOND THE STANDARD CLINICAL READ requested by CHCO Research Institute as well as initiate a contract for the same.


Any question about this form, please contact victoria.bress@cuanschutz.edu.


PROTOCOL DETAILS:

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Date when protocol was reviewed

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Based on the protocol review, provide the additional amount of time it will take to interpret as well as the amount of time spent (if any) with the patient and/or tech for each scan to obtain research data that is ABOVE AND BEYOND THE STANDARD CLINICAL READ. Time estimate should be a minimum of 30 min, with 15 min increments per scan.

Explain or justify why this is a SPECIALIZED RESEARCH READ that is ABOVE AND BEYOND THE STANDARD CLINICAL READ.

List the name of all providers that have agreed to perform research reads (Last, First Name)