Ophthalmology Clinical Trials Billing Form

Ophthalmology Clinical Trials Billing Form

Please complete this form if your Wash U study requires an ophthalmic visit. For further questions, please contact Kelly Reno reno@wustl.edu

Person completing form

Please add your name and email address

Name of PI

Email address of PI

Department name

Select or enter value

Department cost center

This should be in the format of CCXXXXXXX

Please enter IRB number if approved

Study Coordinator name

Study Coordinator email address

Billing contact name

Enter the department person who will handle the approval of SDs in workday

Bill contact email address

Type of Funding

Please choose the most appropriate type of funding for this study

Select or enter value

Who will be billed for this visit?

Will this visit be charged to the study (research), mixture or is considered standard of care

Select or enter value

Sponsor name

Current protocol version/date

Please add the current version and the date

Start date of study

Please give today's date if already active or enter proposed start date

Duration of study (in yrs)

Enter if known

Number of Ophthalmic visits per participant

Predicted recruitment number

Please estimate the number of participants you are hoping to enrroll

Do you expect to need inpatient eye exams?

Select or enter value

Will visits be in the Pediatric or Adult Clinic?*

Select

Can an Optometrist see the participant?

Our clinic at the COH has both Ophthalmologists and Optometrists as well as fellows. Please let us know if your protocol has any restrictions

Select or enter value

Will a member of your team be accompanying

Select or enter value

Paper Source documentation

Does you study require a paper source document to be complete and signed or will you be pulling data from EPIC?

Select or enter value

Certifications or training needed?

Does your study require any ophthalmology employees to complete any training or certification specific to this study?

Select or enter value

Upload images/documents to reading center

Does your study require ophthalmology employees to upload any images/data/documents directly to the sponsors reading center/EDC?

Select or enter value

File Upload

Please attached ophthalmic protocol and any source documents

Drag and drop files here or

Please add Ophthalmology and Visual Sciences Management group to you OnCore entry

Send me a copy of my responses

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