Information regarding use:

FHMGPhysician Payment for Research Services Letter

Purpose:

The purpose of this letter is to confirm and document physician payment agreements when non-billable services are provided as part of the execution of a clinical research trial.

The intent of the letter/form is to provide documentation of a fair and reasonable payment being established to compensate the physician and/or practice for services being conducted as a direct result of study enrollment and protocol compliance for services that are not considered standard or routine care, and therefore, is not billable to the patient or their payer.

Additionally, this provides documentation for accounting to verify and confirm accurate payments are released.

Although the PI name is indicated in the header, the signatory for the physician/physician practice should also be included as a representative of the individual/practice that can and will ensure the following actions:

  • no professional fees will be released
  • proper invoicing to the research department will take place.

Instructions:

□Enter information into indicated fields below.

□Detach instruction sheet from letter; obtain signature of individual authorized to agree on behalf of physician or physician practice. Do not submit the instruction sheet with the form.

□Submit letter to ORA with sponsored budget template for MD services indicated on the NSC tab of the budget template.

□Keep documentation with project contract and budget file.

Detach page from the letter for signature and submission to ORA.

DATE

Practice Administrator’s Name

PRACTICE NAME

ADDRESS

CITY, STATE ZIP

RE: SERVICE: i.e. Biopsy, etc.

For Florida Hospital DEPT NAMEResearch Study

STUDY NAME:VISA

PROTOCOL #: 12345

FH IRBNet #:FH IRBNet PROJECT NUMBER

NCT #: 8-digit NATIONAL CLINICAL TRIAL NUMBER from ClinicalTrials.gov

Dear Mr./Mrs./Ms. ______:

This will confirm our Agreement that Dr. ______:will perform the service listed above for patients enrolled inconnection with the above-captioned clinical study, on behalf of the Florida Hospital DEPT NAME. Attached please find the study’s instructions for the performance and handling of the SERVICE. A copy of each Patient’s informed consent is on file with Florida Hospital’s DEPT NAME and can be provided upon request.

Payment for the service is $______per patient, pursuant to the sponsor’s reimbursement schedule.

Professional and technical fees for this service MUST NOT be billed by your office to the individual’s insurance company. Instead,invoices should be submitted directly to the following (please include patient names, study name, protocol #, and IRBnet # in each invoice along with a copy of your W-9 for payment):

Florida Hospital DEPT NAME

Attn: ___

ADDRESS

CITY, STATE ZIP

If this is agreeable to you, please sign below and return this to me.

Very truly yours,

NAME

TITLE,Florida Hospital DEPT NAME

Accepted and agreed to by:

____

Practice ManagerDatePhysician Date