Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Clinical Trial Site Billing Agreement Form
Principal Investigator Name
Study Protocol Number
Sponsor Organization
Study Start Date
____ / ____ / ________
Total Budget Amount
Payment Schedule
Per-Patient Enrollment Fee
Institutional Overhead Rate
Site Contact Email
Clinical Trial Site Billing Agreement Form template from formisoft.com. formisoft.com/intake-templates/clinical-trial-site-billing-agreement