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Clinical Trial Billing Authorization Form
Billing

Clinical Trial Billing Authorization Form

3 pages•18 fields•HIPAA-ready
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Clinical Trial Billing Authorization Form

Clinical Trial Billing Authorization Form

Page 1 of 3

Participant Full Name
Jane Martinez
Date of Birth
03/15/1985
Clinical Trial Protocol Number
Study Sponsor Name
Jane Martinez
Primary Insurance Information
Insurance carrier & policy
Medicare Beneficiary
Option A
Option B
Option C
Understanding of Sponsor Coverage
Insurance Billing Authorization
I agree to the terms above
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This Clinical Trial Billing Authorization Form provides a clear framework for managing the complex financial aspects of clinical research participation. The form systematically documents which services are covered by the study sponsor, which may be billed to insurance, and any potential out-of-pocket costs for participants. It includes sections for insurance verification, Medicare coverage determination, and detailed authorization for billing submission to third-party payers.

Research coordinators and clinical trial sites use this form to comply with billing compliance regulations and prevent improper charges to participants or insurers. The template captures sponsor contact information, protocol-specific billing procedures, authorization for release of medical information to insurers and sponsors, and acknowledgment of financial responsibilities. It helps research sites maintain regulatory compliance while protecting participants from unexpected medical bills related to their trial participation.

What's included

  • Participant and study identification
  • Insurance coverage verification
  • Medicare coverage determination
  • Sponsor payment responsibilities
  • Standard of care vs. research costs
  • Authorization to bill insurance
  • Release of information consent
  • Financial responsibility acknowledgment
  • Medicare routine cost coverage
  • Secondary insurance details

Who uses this template

  • Academic Medical Centers
  • Clinical Research Organizations
  • Hospital Research Departments
  • Private Research Sites
  • Pharmaceutical Sponsor Sites

All form fields

8 fields across 3 pages. Customize any field after signing up.

Participant Full NameText
Date of BirthDate
Clinical Trial Protocol NumberText
Study Sponsor NameText
Primary Insurance InformationInsurance Info
Medicare BeneficiaryMultiple Choice
Understanding of Sponsor CoverageCheckbox
Insurance Billing AuthorizationConsent Agreement
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