Colpitts Clinical Prepaid Card Request Form

PREPAID CARD REQUESTS
 
  
  • This form is for requesting a PREPAID CARD ONLY.

  • Do NOT use this form if you have already filled out a Travel Request.

  • Important! Required fields are marked with an asterisk.
 
Has this patient transferred from another study?*                
If Yes, indicate which study moving to:
                                                                    
Site Number*
Patient Number*

Full Study Number, Protocol Number or BC#*
Sponsor Name*
Patient Name*
Patient Email Address

        
For Local Patients that do not require TRAVEL RESERVATIONS,
complete the field(s) below for the per diem.
 

Dates for the Per Diem    
Dates for the Per Diem    
Dates for the Per Diem    

Visit Type
(Include the Milestone or Visit type as it pertains to your study)
Please ensure the visit type and date of service are correct prior to submission. Inaccurate information may result in processing delays.
 
Number of Travelers*
Additional Comments
 
Information of Site Coordinator REQUESTING Prepaid Card
Site Coordinator Name*
Site Coordinator  Phone Number*
Site Coordinator Email Address*
 
Information of Person RECEIVING Prepaid Card
Recipients Names*
Recipient's Postal Address to receive cards*
Recipient's Phone Number
Comments:
If the request falls outside the scope of work, please provide a justification so we may seek approval from the sponsor.

Request Justification
(if applicable)
  
Click to print a copy for your records before submitting   

 
 
  
  
 

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