Separation of Allowable Costs
Study Title:
Study Sponsor:
Protocol Number:
Principle Investigator:
Study Coordinator:
Sponsor Contact:
Location of Study:
Planned Enrollment:
Clinical Trial Billing Grid
Procedures
Informed Consent
Concomitant Medications
Medical History
Physical Exam
Vital Signs
ECG
Serum Preg. Test (HCG)
Complete CBC / Auto
Creatinine
AST/ALT
Alkaline Phosphatase
LDH
Sodium
Magnesium
PK
Chest CT
Dose Administration
SAE Reporting
CRF Completion
Other
Misc. Admin
Randomized Phase II Study to Evaluate STUDY DRUG Treatment versus Placebo in
Patient Population
SPONSOR, INC
IURX1234
John Doe, MD
June Smith
Joe Smith
COMPANY ABC
(123) 456-7890; joe.smith@abc.com
University Hospital
5
Baseline
SPONSOR
SPONSOR
SPONSOR
RC
RC
SPONSOR
SPONSOR
RC
RC
RC
RC
SPONSOR
RC
SPONSOR
SPONSOR
RC
SPONSOR
SPONSOR
Week 1
Treatment
Week 2
Week 3
Week 4
Follow Up
Month 2
Month 4
SPONSOR
SPONSOR
RC
RC
RC
RC
RC
RC
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
RC
RC
RC
RC
SPONSOR
RC
SPONSOR
SPONSOR
RC
RC
RC
RC
RC
SPONSOR
RC
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
RC (Routine Care) - Billed to Patient's Insurance; SPONSOR-Billed to Sponsor
Office of Research Administration (03.2010)
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
SPONSOR
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Separation of Allowable Costs
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Please Check Appropriate Reimbursement Source
Principal Investigator:
Study Title:
Sponsor:
Research
(Required by study
and paid by sponsor)
Routine Care
(Standard of Care- to be
paid by insurer/patient)
A. STARTUP COSTS (non-refundable):
Investigator Meeting
Coordinator Meeting
IRB Fee:
Protocol & Consent Form Review, Submission & Closure:
Administrative Fee:
Storage:
Pharmacy Set Up & Storage:
Other:
B. OTHER COSTS:
Travel
Site Training
Advertising
Equipment
Dry Ice
Space rent
Other
C. PER PATIENT COSTS:
Screening Assessment :
EFFORT-BASED COSTS
Informed Consent
Inclusion/Exclusion Criteria
Chart Review
Medical History
Randomized Phase II Study to Evaluate STUDY DRUG Treatment
Vitals & Blood Pressure
versus Placebo in Patient Population
Study
Title:
Physical
Examination
Review Adverse Reactions
Office of Research Administration (03.2010)
Medication Dispensing/Returning
EXPENSE-BASED COSTS
Clinic Visit
X rays & Scans
Separation of Allowable Costs
Study Sponsor:
Protocol Number:
Principle Investigator:
Study Coordiantor:
Sponsor Contact:
Location of Study:
Planned Enrollment:
SPONSOR, INC
IURX1234
John Doe, MD
June Smith
J. Smith
COMPANY ABC
(123) 456-7890; joe.smith@abc.com
University Hosp.
5
Clinical Trial Billing Grid
Procedures
Informed Consent
Concominant
Medications
Medical History
Baseline
Physical Exam
Vital Signs
ECG
Serum Preg. Test (HCG)
Complete CBC / Auto
Creatinine
AST/ALT
Alkaline Phosphatase
LDH
Sodium
Magnesium
PK
Chest CT
Dose Administration
SAE Reporting
CRF Completion
Other
Misc. Admin
$100.00
$50.00
$135.00
$35.00
$100.00
$25.00
$40.00
$30.00
$10.00
$10.00
$10.00
$40.00
$1200.00
Routine Care-billed to Ins.
Week 1
Treatment
Week 2
Week 3
Week 4
Follow Up
Month 2 Month 4
$50.00
$50.00
$100.00
$50.00
$100.00
$50.00
$100.00
$50.00
$25.00
$25.00
$40.00
$30.00
$10.00
$10.00
$10.00
$40.00
$100.00
$25.00
$40.00
$30.00
$10.00
$10.00
$10.00
$40.00
$1200.00
100.00
$25.00
$40.00
$30.00
$10.00
$10.00
$10.00
$40.00
$50.00
$35.00
$50.00
$35.00
$150.00
$50.00
$200.00
$50.00
$35.00
$20.00
$50.00
$35.00
$3000.00
Sponsor-Billed to sponsor
Office of Research Administration (03.2010)
$20.00
$50.00
$35.00
$50.00
$20.00
$50.00
$35.00
$20.00
$50.00
$35.00