Clinical Trial Billing and Coverage Agreement

The Clinical Trial Billing and Coverage Agreement is a financial disclosure document that clarifies payment responsibilities for patients enrolling in clinical research studies. Clinical trials involve a complex mix of investigational procedures paid by the research sponsor and routine medical care that may be billed to the patient's insurance. Without clear documentation, participants can receive unexpected bills, and research sites risk compliance violations related to improper cost allocation. This agreement serves as the definitive record of which party is responsible for each category of expense, ensuring that patients enter the study with full understanding of the financial implications of their participation.

The form captures detailed information needed to categorize and process trial-related billing accurately. It records the study sponsor name, protocol number, and principal investigator contact details for reference. A structured checklist allows coordinators to designate specific procedures, laboratory tests, imaging studies, and medications as either sponsor-covered research costs or standard-of-care items billable to insurance. The agreement documents the patient's primary insurance carrier, policy details, and verification status. Additional sections address estimated co-pays and deductibles for routine care services, potential out-of-pocket costs not covered by either the sponsor or insurance, and the process for resolving billing disputes that may arise during the study. The patient signature section confirms understanding of all financial terms.

This agreement is essential for academic medical centers, contract research organizations, hospital research departments, pharmaceutical trial sites, and medical device study centers. It supports compliance with Medicare's Clinical Trial Policy (NCD 310.1), which requires that qualifying clinical trials distinguish between investigational items and routine care costs for coverage determinations. The form also satisfies institutional review board (IRB) requirements for financial transparency in the informed consent process. By establishing clear financial expectations before enrollment, the agreement reduces billing errors, prevents improper charge allocation that could trigger federal audit findings, and improves participant satisfaction and retention throughout the study duration.

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Clinical Trial Billing and Coverage Agreement from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.