PATIENT EXPENSES
 
  • This form is for submitting patient expenses for reimbursement.
  • Note: A Patient Profile form is required to be filled out before initially submitting any forms on the portal. The completed profile needs to be filled out only once, as it will be stored for future reference in all future form requests.
  • Important! Required fields are marked with an asterisk.
  • Expense Reimbursement will be processed within 10-14 days of submission

  • Download Copy of Expense Sheet
  • After opening the downloaded Expense Sheet, please “save as” a copy before completing.

 

Site Number
Patient Number*
Full Study Number, Protocol Number or BC#*
Sponsor Name
Patient's First Name
Middle Name
Last Name

Type of Visit or Milestone

(If applicable, please provide this information should this be an important factor for us to have for any of the travel logistics)
Please ensure the visit type and date of service are correct prior to submission. Inaccurate information may result in processing delays.
 
 
   SITE COORDINATOR INFORMATION
Site Coordinator Name*
Site Coordinator Phone Number*
Site Coordinator Email Address*
Site Address*
TOTAL AMOUNT
Total Amount on Form
If the request falls outside the scope of work, please provide a justification so we may seek approval from the sponsor.
Request Justifiction
(If applicable)
 
 
 Upload Expense Sheet and Receipts (Total file sizes can not exceed 50MB)
Upload Expense Sheet
Receipts Upload 1
Receipts Upload 2
Receipts Upload 3
Other Document Upload

 

Click to print a copy for your records or save as a pdf before submitting   

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