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Currency [0]/Explanatory TextG5Explanatory Text %0 : Followed Hyperlink 1Good;Good  a%2 Heading 1G Heading 1 I}%O3 Heading 2G Heading 2 I}%?4 Heading 3G Heading 3 I}%235 Heading 49 Heading 4 I}%6( Hyperlink 7InputuInput ̙ ??v% 8 Linked CellK Linked Cell }% 9NeutralANeutral  e%"Normal :Noteb Note   ;OutputwOutput  ???%????????? ???<$Percent =Title1Title I}% >TotalMTotal %OO? Warning Text? Warning Text %XTableStyleMedium9PivotStyleLight16M֝EW5 LWM] X du0066122 - Personal View`YGrid InstructionsqSheet1}Protocol Billing GridPatient Tracking Grid% devcategory;% gridheading; IDnum;& providerlist;))" studytyp;# studytype;# typestudy;Sfvf`@'&@jb(+3 A@@  |bInformed ConsentScreenPI Fee Department:Pt reimbursement for travelCoordinator Fee Study Title:IRB No:PI: Contact No:Date Completed:Visit 1Visit 2Visit 3Visit 4Visit 5Sponsor:STUDYSOC Procedures*ECG HematologySerum Preg. Test Visit 6 or EWFUNAColumn A Column A: Column B:Column BColumn C Column C:^2. Please complete the Grid based on the requirements of the protocol in the following manner: Coordinator: Completed By:ENTER DATA IN THIS COLUMNNotes:#Consent/Contract or Other Comments:Patients Name, Study IDDOBMRN Consent DateDate OFF Study"Arm of Study (Control, Invetigat.)~The Patient Tracking Grid Template will be used to help track patient visit dates for each visit associated with the protocol."1. This form should auto generate the study data and patient visits from Research Billing Grid. You can add other columns for unscheduled visits by going to the last "visit" column, going to insert, and clicking on column. \2. Save the grid. You can go in and list the patient information and visit dates as you go.1. This form should be completed by the coordinator or PI of the study prior to developing the budget (if applicable) and submitting the IRB application. The grid should be attached to your IRB submission under "other documents."{Please list the services and procedures required by the protocol. Also list device or supply items provided by the study. Initial Office Visit (MD)FU Office Visit (M.D.)Clinical ResearchDevice Study Type: IDE category AIDE category B devcategoryerrorClinical typestudyPostmarketing DeviceHumanitarian UseIdnumIDE #HUD #PMA #=*Please indicate in box under each visit if the procedure is:Enter a date for each visit.Indicate "STUDY" if the service or procedure is to be billed to the study. Indicate "SOC" if the service or procedure reflects standard of care and should be billed to insurance. Administrative Non-Billable Billable Protocol Procedures*Notes3These patients are already regular clinic patients.*This Page Instructions Only. See Next Tab.IDescribe Study Type (device or clinical research) using drop-down menus: Protocol Billing Grid:Please list the visits in column C based on the protocol. DExample: Consenting, Patient Stipend, Survey, Research QuestionnaireZServices that potentially generate a bill. Example: blood draws, radiology, clinic visitsDone after clinic visit. PK samplingJDrawn w/ SOC labs, but processed by coordinator and shipped out centrally.EXAMPLE: PROTOCOL BILLING GRIDPatient Tracking GridThe Protocol Billing Grid will be used to outline study related versus routine clinical services within a study protocol. This document should guide preparation of the Research Budget and patient Informed Consent Form. This form is required for all clinical research projects.CPT Code (optional)Optional- please list the 5 digit CPT, ICD-9, or DRG codes if known. If there is not a code for the service or procedure, please list NA (not applicable).1University at Buffalo Protocol Billing Grid (PBG) NCT Number:If Device, IDE NumberKCOVERED BY STANDARD OF CARE/Usual Care (list): SOC (billable to insurance)DCOVERED BY THE RESEARCH/STUDY (list): STUDY (billable to the study)"CLINICAL RESEARCH OFFICE SIGNATURE.The coverage analysis provided is complete and accurate based on the information provided to this office by the Principal Investigator related to the study identified above. This office is not responsible for any errors in the event the information provided was incomplete, inaccurate, or out of date.DATEScreening (Baseline)Visit:If you have questions regarding this form, please contact The University at Buffalo Clinical Research Office at 888-4844 or email CAreview@buffalo.edu jGI IJyJ>JKxNuOvPQKIS U XccB T8 $qxÅ  dMbP?_*+%&C&"Arial,Bold"&16EXHIBIT B&?'?(?)?Mhp LaserJet 1320 PCL 5eC odXLetterDINU"deN8SMTJhp LaserJet 1320 PCL 5eInputBinFORMSOURCERESDLLUniresDLLHPDocUISUITrueESPRITSupportedTrueOrientationPORTRAITHPOrientRotate180FalseMediaTypeAUTOOutputBinMainBinFaceDownEconomodeFalseTTAsBitmapsSettingTTModeOutlineRETChoiceTrueAlternateLetterHeadFalseHPColorModeMONOCHROME_MODEHPPDLTypePDL_PCL5HPMaxResolutionPDM_600DPIHPPJLEncodingUTF8HPJobAccountingHPJOBACCT_JOBACNTHPBornOnDateHPBODHPJobByJobOverrideJBJOHPDuplicateJobNameOverrideSWFWHPManualDuplexDialogItemsInstructionID_01_FACEDOWN-NOROTATEHPManualFeedOrientationFACEUPHPOutputBinOrientationFACEDOWNHPManualDuplexDialogModelModelessHPManualDuplexPageOrderEvenPagesFirstHPMapManualFeedToTray1FalseHPPrintOnBothSidesManuallyFalsePSAlignmentFileHPCLS5r1PSServicesOptionHLPWithLightsHPSmartHub_OnlinediagnostictoolsTRUEHPSmartHub_SupportandtroubleshootingTRUEHPSmartHub_ProductmanualsTRUEHPSmartHub_CheckfordriverupdatesTRUEHPSmartHubInet_SID_263_BID_276_HID_265HPStraightPaperPathFalseHPPosterPrintingFalseHPPosterPrintingOptionPOSTER_2HPDocPropResourceDatahpchl5r1.cabHPNUseDiffFirstPageChoiceTRUEHPPageExceptionsFileHPCPE5r1HPPageExceptionsInterfaceShowPageExceptionsHPPageExceptionsLowEndHPPageExceptionsLowEndVerHPPageExceptionsCoverInsertionHPConsumerCustomPaperTrueHPEnableRAWSpoolingTrueResolution600dpiGraphicsModeRASTERMODEPaperSizeLETTERDuplexNONEPrintQualityGroupPQGroup_1HPXMLFileUsedhpc13205.xmlHPSmartDuplexSinglePageJobTrueHPSmartDuplexOddPageJobTrueHalftoneHPDitherMatrixTextAsBlackFalseHPFontInstallerTRUEIUPHxoABbEi7/{#QAlwBئ+D< `` ^8x5fAOnXiLǛ}y3',^%ZDi a"=;QΣBK͋DF-B'Ԡ&GOABlc>ըLiwD )xw^w$' CdDCd"\j\¹>s|E5i 6KIKpFq6Va? /S O d 3GpdPKltJ+뤬Z+4M7X\ q%I8+̒Ǿ`uAMEs *~}5AAAA8"PX??&U} }  }  } I$  h h v@  +@    , v@ @ @ h ;      G@  +@   @    @         I@ WV T YYYYYYYYYYYYY / YYYYYYYYYYYYY Y YYYYYYYYYYYY YYYYYYYYYYYYY Z 0  V   L   Y D  I  R YY U U   U K K K K K K K  K  G  F  N  1~ 8@ NLLLLLL  H  2~ 8@ NL LL LL N ~  @ N LL L LL L P N LL LL L L  Q  ~ @ N LL LL L L ~ @ NL LL LL L E  M    NLLLLLL  O    O O O O O O O      O L L L L L L          GGGGGGGGGG , - B X 0$0$0$<<<800HF^zt~F^0 ,@! 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