Clarian

  Clarian Forms:
   Request for
       Research Services

   Lab Director CV

   Grant Form

  Templates:
   Budget Template

Pathology & Lab Information

Clarian Pathology Laboratory
350 W. 11th Street
Indianapolis, IN 46202

Clarian Pathology Website:
Clarian Pathology Laboratory can be accessed for a variety of needs, ie: lab
normal values, regulatory certifications (CAP & CLIA for Clarian Path Lab), etc.
For research requisitions, download the Request for Research Services form
in the Resources list to the right.

Clarian Grant Form

Research Grant Process

Study Participant (Research Subject) Information:

  Inform all study participants that they will need to provide Legal Name, Date of Birth, Address and
    Emergency Contact. Emphasize that Emergency contact will only be utilized should there be actual on
    site emergency.

  Indicate they will be asked to provide insurance information should “standard of care” services be
    expected. Patient can opt to pay out of pocket if they decide to leave insurance out of care.

  Information that already exists in computer systems will NOT be deleted due to the possibility that the
    patient is followed at other Clarian site(s).

  All necessary Consents should be reviewed and signed prior to study participation.

Principal Investigator (PI) or Delegate Responsibilities:

  Contact Patient Financial Services (PFS) to establish a new Clarian / IU vendor grant, receive a blank
    form. Provide PFS with a copy of the IRB approval. Proceed to complete “the form” (see Attachment #1)
    specific to the study for subject use and fax or email a copy to PFS upon completion.

  Communicate with service sites should additional services be expected to assure insurance collections
    and pre-certification as applicable. This includes any procedure/supplies outside of grant approved
    services. Ex. Antibiotics, Biopsy, Procedures etc.

  Check off all charges or write “all charges covered by grant” on the form to assure all charges get billed
    to Grant. Communicate with Patient Financial Service (PFS) should additional (more than listed on the
    form) services become covered for that specific participant.

  Complete the form on all study participants. Suggest having specifics pre-printed on the form, listing only
    services to be billed to the grant account. Services billed to the patient/3rd party are not listed on the
    form. Assure all sites have the form at the time of patient visit or prior to the patient arrival.

  Coordinators need to assure that a copy of the form gets to all applicable billing sites to assure billing
    appropriately. Ex. Private Practice, Radiology/Radiologist, Path, Lab etc.

  Coordinator or designee will determine “who pays for services” if grant is not budgeted with all
    additional services. Ex. Adverse events, additional meds, procedures.

Research Study Participant (Subject) Flow

Scheduling Appointments

  Coordinators will schedule all study participants according to each service site’s process.

  Service site will indicate patient type as “Study/Research” as comment in system.

Study Participant Arrival

  Service sites will have knowledge of participant’s arrival via scheduling and Registration/Grant Form,
    which is an abbreviated registration process. Participants should not have to complete full registration, if
    form is complete with all needed information.

  Should participant already be an existing Clarian patient, the existing information will not be deleted
    from computer systems.

  Grant Account expenses should be listed by the coordinator on the form. Procedures not listed on the
    form will be the patient/3rd party responsibility, which will then require full registration.

Check Out

  Follow each service area’s department’s process.

  Service area will enter all charges into appropriate computer system and fax to Camille Gilliam (or the
    appropriate PFS - Patient Financial Service personnel) the new completed Vendor form within 48 hour
    window from date of service.

  System places all charges in hold pattern until PFS directs to the Grant or to Insurance.

  It is noted that, the IU Department delegate for FIS (Financial Information Services) will receive
    itemization for review and verification by this person and/or the coordinator.

  Any charges denied by IU Department delegate will go through the PFS denial process. PFS will file
    patient insurance or bill participant for any non-grant covered services. Refer to Attachment #3.

  If non-research staff are utilized, i.e.: Phlebotomy, Injection, etc., charges will occur.

  The Research Registration/Grant Charge Form (“the form”) will only list Grant Approved Services. Service
    Sites should review all items that are listed for that visit.