ࡱ> &% \pLuchs, Melanie S Ba==<=, 8X@"1Arial1Arial1Arial1Arial1Arial1Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                + ) , *      @ @ "0@ @ *0@ @ "0 @ (0@ @  0@ @  0@  0@ (p@ @  p @ *0@ @ "0@ @  @ (p@ @ 9  `@@ 9  p@ 9  `@ 9  ` @ 9 *p @ 9  @   @     @   @ #0  @     0@ @  0@  0@  0@@  0@  0 @  0@  0  0  0@  0  0  p@ @   0@ @ (0@ @  p@ @ "p@ @ 3  p@ @ 3 `Sheet1"@>: Study Title:Sponsor: Protocol No.:IRB No.:Principal Investigator: Department: Coordinator: Completed By:Date Completed:%Describe Study Type (device or drug):=RPO - Use if the service or procedure is billed to the study.cSOC - Use if the service or procedure reflcts standard of care and should be billed to third party.CPT Code (If available) Protocol Services and Procedures Procedure 1 Procedure 2 Procedure 3 Procedure 4 Procedure 5 Procedure 6 Procedure 7 Procedure 8 Procedure 9Administrative Non-BillableInformed ConsentCoordinator FeePI FeeSubject Compensation Comments:NAScreen TreatmentVisit 10Visit 11Visit 12Month 9Month 12Month 15Month 18Month 21Month 24NotesZServices or Procedures that potentially generate a bill, Example: blood draws, radiology. Follow-Up PI SignatureDateCoordinator SignaturePROTOCOL BILLING GRIDEnter Data in This ColumnVisit 1Visit 2Visit 3Visit 4Visit 5Visit 6Visit 7Visit 8Visit 9B8 m A /  Z.cc  4 '  dMbP?_*+%(?)?M*HP LaserJet 1200 Series PCLLC odXXLetterDINU"LJ4SMTJHP LaserJet 1200 Series PCLInputBinFORMSOURCERESDLLUniresDLLPaperSizeLETTEROrientationPORTRAITOptimizeForPLAINResolutionOption1HalftoneHT_PATSIZE_AUTOEconomodeOption1"=XX??U} $}  } } } } 4:@     @@@@H@ 3/433333333333333333333333 @02@@@@*****************+ 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4AAAAA,,,,,,,,,,,,,,,,,- 4 AAAAA,,,,,,,,,,,,,,,,,- 4 AAAAA,,,,,,,,,,,,,,,,,-6 AAAAA,,,,,,,,,,,,,,,,,-  4 AAAAA,,,,,,,,,,,,,,,,,-6 .,,,,,,,,,,,,,,,,,,,,,,- . 4,,,,,,,,,,,,,,,,,,,,,,- . 4,,,,,,,,,,,,,,,,,,,,,,-6.,,,,,,,,,,,,,,,,,,,,,,-A B 4 A EEEEEEEEEEEE4 D+DDDDD-AA6A 1 2 3 4 5  6  7  8  9   ! !"5 "# $ % & ' ( ) $ 2%&'''''''''''''&'''''( )* 4#5#4 455 455 455 455 455 455 455 466 4CCCCCCCCCCCCCCCCCCCCCC   2444  2555Df lFNFFFFFFFFF:F:FF:&RFFFFFFFFFFR !"#$%&'()*+,-./01 23  2 555 ! !2!6666".,,,,,,,,,,,,,,,,,,,,,,- #.4#788888888888889,,,,,,,-6$.:;;;;;;;;;;;;;<,,,,,,,-6%.:;;;;;;;;;;;;;<,,,,,,,-6&.:;;;;;;;;;;;;;<,,,,,,,-6'.:;;;;;;;;;;;;;<,,,,,,,-6(.:;;;;;;;;;;;;;<,,,,,,,-6).=>>>>>>>>>>>>>?,,,,,,,-6*.,,,,,,,,,,,,,,,,,,,,,,-6+.,,,,,,,,,,,,,,,,,,,,,,-6,.,,,,,,,,,,,,,,,,,,,,,,-6-.,,,,,,,,,,,,,,,,,,,,,,-6..,,,,,,,,,,,,,,,,,,,,,,-6/.,,,,,,,,,,,,,,,,,,,,,,-60.,,,,,,,,,,,,,,,,,,,,,,-61/,- 2.,2,,,,,,,, 2 ,-2 , 2 ,.2 ,,,,,,,,,, 20-2-6312,|RR:F::::::::::::::>@      !#)!!7 Oh+'0HPp Ruthie Lynnette RustonMelanieMicrosoft Excel@.'W@MO"W@ W՜.+,0 PXd lt|  Sheet1  Worksheets  !"#$Root Entry F'\'Workbook(SummaryInformation(DocumentSummaryInformation8