Research Registration/Grant Charge Form Date of Service: ____________ Patient Information Patient Name (as it appears in Master Study Addendum Cerner): Patient Medical Record Number (MRN): Patient Date of Birth (DOB): Sex: Male Female Fill in the appropriate areas Vendor Name (Study ID): Preferred Billing Account #: Provided by IU Health Revenue Cycle Services Where Applicable (School of Medicine) PO #: Account # (account to be billed): Required Administrative Contact: (name/phone/email) Required *Please note Bill(s) will be sent to – this individual Detailed Procedure Description IU Health Profee CPT No Radiology Service Department/Area Cost Center # Service Code Code Read Exam/Consult Room 59905687 Instructions Completed form must be emailed the date service is rendered to . If trial is a radiology charge, please cc: . *Please enter the name of the clinical in the email subject line*
Research Registration/Grant Charge Form Date of Service: ____________ Patient Information Patient Name (as it appears in Cerner): Master Study Addendum Patient Medical Record Number (MRN): Patient Date of Birth (DOB): Sex: Male Female Fill in the appropriate areas Vendor Name (Study ID): Preferred Billing Account #: Provided by IU Health Revenue Cycle Services PO #: Where Applicable (School of Medicine) Account # (account to be billed): Required Administrative Contact: (name/phone/email) *Please note – Bill(s) will be sent to this individual Required Detailed Procedure Description IU Health Service Code Profee CPT Code No Radiology Read Service Department/Area Cost Center # Exam/Consult Room 59905687 Instructions Completed form must be emailed the date service is rendered to . If is a radiology charge, please cc: . *Please enter the name of the clinical trial in the email subject line*
Research-Billing-Packet_Form-2-with-completion-guide.docx