Complete the Following Table: Include All Services/Items from the Schedule of Event To

Cytogenetics Pathology Researcher Information: Obtaining Pricing for Cytogenetics Services

Obtaining Service Codes and Pricing for Cytogenetics Services:  Researcher completes the attached Confirmation of Services (COS) form, which includes study information, tests requested volume, any turn-around requirements and time periods. (White areas to be completed by study team; Shaded areas are to be completed by Cytogenetics personnel). Note: If Researcher is unsure of correct CPTs code to request, these can remain blank and the lab will use protocol to help determine correct CPT codes needed.  Researcher indicates in comments any of the following special handling requirements: o Are there any special documentation (reporting) requirements, beyond the laboratory's standard clinical reports (i.e., special forms to be completed, extra copies of reports, images, re-writing reports in specific formats, etc.)? o Will there be any requirements for the packaging, shipping, and/or delivery of prepared materials (i.e., tissue cultures, cell pellets, extracted DNA, etc.) to the PI, sponsor, or any other third parties? o Will there be any requirements for computer data entry (i.e., entries or submission to patient registries)? o Will there be any requirements for the production of digital images to be prepared for distribution? o Any other special requests?  Researcher contacts Brian Gray requesting Confirmation of Services via e-mail  ([email protected]) or FAX: (352) 265-9920. The request should include: o Completed COS form o Current Protocol  Cytogenetics staff will review the request and confirm CPT Codes, then add pricing (both List Price and Medicare Estimate) and complete shaded lab box in upper right corner.  Cytogenetics staff will also assign CPT codes to any special handling requests.  Cytogenetics staff will return the completed COS form to the researcher’s contact person.

Obtaining R99 number and setting up Research Order Forms:  Researcher will submit a complete compliance p acket, including the COS from Cytogenetics, to Research Administration & Compliance (RAC) with rest of the submission documents (protocol, budget, Informed Consent Form, etc.)  RAC staff will review documents and send on to Shands and UFP for final pricing confirmation and creation of R99 number for the study.  RAC staff will email final pricing confirmation and R99 to Researcher and Cytogenetics staff.  Once R99 is set up, Cytogenetics Staff will provide Study Team with yellow research order forms with box for entering R99 number.

Ordering Study-Paid services using Research Order Forms and R99:  To ensure proper billing, Study Teams MUST use the yellow research cytogenetic order forms ONLY and insert the correct R99 number and contact information.

Cytogenetics Confirmation of Services Page 1 of 2 Version 12/13/10 Cytogenetics Pathology Researcher Information: Obtaining Pricing for Cytogenetics Services

 Please do not begin to order labs for your study until you receive your R99 account number AND the yellow research order forms.  The yellow forms MUST be used for all sponsor-paid specimens for a given study, and must accompany any patient or specimens sent to lab for testing.  Reminder: Admissions, PFS, and University of Florida Physicians (UFP) billing personnel should be notified of inpatients by email to alert them to the patient's research services (see RAC Clinical Trials Compliance website, http://ctc.health.ufl.edu/, for further information).

Billing for Study-Paid Services:  Once the research orders are received, the lab will process the order and Cytogenetics staff will enter the services into IDX.  UFP will issue invoices to the study’s R99 account.

This process has been implemented to ensure that studies are billed correctly. Please help us by following this procedure. If you have any technical questions about this process, please contact: Brian Gray Robert Zori, MD Supervisor, Cytogenetics Lab Professor and Chief UF Path Labs Division of Genetics and Metabolism 4800 SW 35th Drive Department of Pediatrics UF College of Medicine University of Florida Gainesville, FL 32608

TEL: (352) 265-9900 FAX: (352) 265-9920

For billing and pricing inquiries please contact: Naomi Williams Coord. of Budget UF Path Labs 4800 SW 35th Drive University of Florida Gainesville, FL 32608

Tel: (352) 265-9900 FAX: (352) 265-9901

Thank you for your business and cooperation in using the yellow R99 forms for your ordering.

Cytogenetics Laboratory Staff

Cytogenetics Confirmation of Services Page 2 of 2 Version 12/13/10 UF PathLabs Cytogenetics Confirmation of Services (COS) Form for Research ( STUDY TITLE: RESEARCH TEAM Send Request for Confirmation of Services to: Principal Investigator: Other Study Investigators/Providers (list all by name) : Cytogenetics Pathology Services Brian Gray [email protected] Study Contact Person Submitting Form: Telephone: (352) 265-0111 72009 FAX: (352) 265-9920 Email: http://www.pathology.ufl.edu/~drl/cyto/cytolab.htm Phone: Fax: To be completed by Cytogenetics Lab: PO Box: Date Study Contact submitted to Cytogenetics Lab: Estimated Dates Services will be ordered for study: Cytogenetics Lab Contact Completing Form: Start Date: End Date: Cytogenetics Lab Contact Email: Date Completed & Returned to PI/Study Contact: Please check the Special handling needed beyond labs’ standard reports (explain in comments below) Pediatric Patients Outpatient following as Amendment to R99 issued prior to 09/27/10 Adult Patients Inpatient appropriate: Federally-funded study For budgetary purposes on multi-year studies, plan for a 5% price increase each year. Medicare rates are estimates. Actual charges will be rate current on day of service.

Anticipated # of Global Global Turn-around Service Name # Tests per CPT/Service Code List Price Medicare Estimate Requirements (if any) of Patients Patient (Cytogenetics UFP Use Only) (Cytogenetics UFP Use Only)

COMMENTS (Include requests for special handling needed beyond labs standard clinical reporting process; See Page 1 of Instructions; ):

If you need more space, unprotect document and add more rows or use additional COS forms from the RAC website. Number of Additional COS Attached: By submitting this form to the Research Administration & Compliance Office, the Principal Investigator of this study attests that the services and codes listed are complete and correct as required by the study protocol and that (s)he has collaborated with the appropriate service department to obtain all information as provided.

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