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IF THIS IS THE FIRST TIME YOU HAVE USED THIS ONLINE FORM PLEASE CONSIDER READING ABOUT CPT Lookups.

RESEARCH CLINIC:

ASSESSMENT OF CLINICAL IMPACT / ATLANTA VA MEDICAL CENTER

1. Title:
2. IRB Approval Number:
3. Sponsor: 3.a. Administered By:
4. Principal Investigator:
5. Anticipated Starting Date: Pick a date
6. Anticipated Closing Date: Pick a date
7. Planned # of Research Subjects: Veterans: Non-Veterans: Total:
8. Planned # of Non-Veteran Subjects Requiring Procedures:

9. a. Radiology Procedures: Yes No

Please note that if you have clicked yes and later change your answer to no it will clear the Radiology answers.

Procedure Code # of Patients X-rays / Patient X-rays / Patient above and beyond normal patient care Cost Per X-ray Total Cost
SubTotal
VA Reimbursable SubTotal
Radiology Signature Icon

9. b. Nuclear Medicine Procedures: Yes No

Please note that if you have clicked yes and later change your answer to no it will clear the Nuclear Medicine answers.

Procedure Code # of Patients Procedure / Patient Procedures / Patient above and beyond normal patient care Cost Per Procedure Total Cost
SubTotal
VA Reimbursable SubTotal
Nuclear Medicine Signature Icon

10. Other Ancillary or Specialty Tests: Yes No

Please note that if you have clicked yes and later change your answer to no it will clear the Ancillary or Specialty Tests answers.

Procedure Code # of Patients Procedure / Patient Procedures / Patient above and beyond normal patient care Cost Per Procedure Total Cost
SubTotal
VA Reimbursable SubTotal
Chief Signature Icon

11. Inpatient hospital care for research study: Yes No

Please note that if you have clicked yes and later change your answer to no it will clear the Inpatient hospital care answers.

Patient Days   # of Patients   Cost / Day   Total Cost
x x =

12. Clinical Laboratory Procedures: Yes No

Please note that if you have clicked yes and later change your answer to no it will clear the Clinical Laboratory Procedures answers.

Procedure Code # of Patients Procedure / Patient Procedures / Patient above and beyond normal patient care Cost Per Procedure Total Cost
SubTotal
VA Reimbursable SubTotal

Lab Signature Icon

 

Totals

Total Cost
Total VA Reimbursement

 

Signatures:

I understand that the project must reimburse the VAMC for the procedures outlined above if they are performed on Non-Veterans or when performed on Veterans above and beyond normal patient care.

PI Signature Icon Directory of Research Operations Signature Icon
Executive Director Signature Icon  

NOTES:




Non-Veteran patient care services are always reimbursable to VA.
Costs are determined by current billing practices by VA.

Generated on 07/20/2019 at 03:57 54 AM by CPT version 0.3