Radiology Imaging RESEARCH READ Billing

Radiology Imaging RESEARCH READ Billing

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 research reads that are requested by CHCO Research Institute.

Information collected through this form is based on the Protocol Review and Research Read Budgeting form and will also be used to invoice CHCO Research Institute.

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

Research Read Provider (Last, First Name)*

CU Med Provider ID#*

PROTOCOL DETAILS:

IRB #*

For each IRB#, use a different form

How Many Research Reads?*

Select

1st Scan Date*

1st Research Read Date*

Date when research read was performed

1st Research Read - Patient Study ID# and anatomical region*

1st Research Read - Total # of Reads*

2nd Scan Date*

2nd Research Read Date*

2nd Research Read - Patient Study ID# and anatomical region*

2nd Research Read - Total # of Reads*

3rd Scan Date*

3rd Research Read Date*

3rd Research Read - Patient Study ID# and anatomical region*

3rd Research Read - Total # of Reads*

4th Scan Date*

4th Research Read Date*

4th Research Read - Patient Study ID# and anatomical region*

4th Research Read - Total # of Reads*

5th Scan Date*

5th Research Read Date*

5th Research Read - Patient Study ID# and anatomical region*

5th Research Read - Total # of Reads*

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