Research Requestor Checklist for Establishing a Clinic Code Form Policy

This policy rescinds any previous policy covering the same material.

  1. PURPOSE

To outline the process of Children’s Health System (CHS) Research Requestor Checklist for Establishing a Clinic Code Form and components.

II.DEFINITIONS

A.Requestor name:The name of the UAB/CHS RC.

B.Phone Ext: The telephone number of the UAB/CHS RC.

C.Date Submitted: The date the form is submitted to the CHS Grants and Research department by email or fax.

D.Required Completion Date: The date in which the study code needs to be set up by CHS IT in CHSAccessCenter for registering the research patient.

E.Sub-Specialty/Division: The name of the sub-specialty or division of the Access Center Clinic or ancillary department at CHS for treating the research patient.

F.Physician name: The name of the physician (PI) treating the research patient.

G.Preference for Clinic Code (5 characters): The assignment of a five character study code for the tracking and identifying the research patient staring with number “9”. The remaining four positions can by all numeric characters or all alphabetic characters or a combination of numeric or alphabetic but no special characters, such $,#, etc.

H.Clinic/Location: The AccessCenter clinic for the treating the research patient.

I.Is this a Grant or Study? If Yes, provide Grant Information: Grant Title: The grant research title of the study protocol for the research patient at CHS.

J.IRB Approval #: The IRB approval number for treating the research patient at CHS.

  1. BACKGROUND

This form is used internal tracking all CHS studies through Children’s Hospital Health System including Children’s Hospital and Children’s South facility for billing purposes.

  1. REGULATIONS

This is an internal form used by CHS Health System for tracking and recording all research patients preventing insurance duplication in the billing system.

V.POLICY

  1. UAB and CHS RC (research coordinators) provide form for setting up research study code to the CHS Grants and Research Department for billing purposes.
  1. CHS Grants and Research Department assigns cost center and transmits form to Specialty Care Director for approval.
  1. CHS Specialty Care Director transmits form to CHS IT which is coded and set up in the CHSAccessCenter for registration of the research patients for billing purposes.

VI.EXCEPTIONS

Any exceptions or deviations to this policy may only occur with the written authorization of the Chief Executive Officer or his designee.

11/8/2010