Patient Expense

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.

Fill in Patient information and attach Expense Sheet and Receipts in the fields provided.

Expense Reimbursements will be processed within 10-14 days of submission

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
Total Amount on Form

Upload Expense Sheet and Receipts
Upload Expense Sheet
Receipts Upload 1
Receipts Upload 2
Receipts Upload 3
Receipts Upload 4
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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