Study Team COS Requests must be done using the following form and process:
GENERIC COS FORM (version 9/12/23)
Do NOT use this form for the following UF Health service locations – they have their own COS forms:
- Cardiac Cath Lab
- Cytogenetics
- Investigational Drug Services (IDS) (requires Gatorlink)
- Lab & Pathology
- Operating Room, Anesthesiology, and Surgery
- Radiology – Radiology Process for New Research (requires Gatorlink)
- UFHP Clinics
- UF CTSI Clinical Research Center (UF CRC)
INSTRUCTIONS FOR FILLING OUT THE GENERIC COS FORM
LOCATION OF SERVICES (ONE LOCATION PER FORM)
- To select location of services on the Generic COS Form, click where it says “click here for location list” and then click the arrow to the right to view a drop-down list. Use this menu to select the Shands Ancillary location where services will be administered.
STUDY SHORT NAME (NICKNAME)
- In the free text field next to “Study Short Name (nickname): enter the study short name (nickname) that will be used by the Principal Investigator/Study Coordinator(s) to reference the study.
- This short name will be used as an identifier for this study on all forms and will be used as the searchable “Study Name” when the study is in Epic (limited to 20 characters).
STUDY LONG TITLE
- In the free text field next to “Study Long Title:” enter the study title (limited to 256 characters).
- Note: This should match the study title that will be submitted to your IRB and CRH Submissions.
PRINICPAL INVESTIGATOR
- In the free text field next to “Principal Investigator:” enter the full name of the Principal Investigator.
- Note: This information should match the PI that will be submitted to your IRB and CRH Submissions.
OTHER STUDY INVESTIGATORS/PROVIDERS
- In the free text field next to “Other Study Investigators or Providers (list all by name):” enter the name of any other investigators or physicians that may be providing services for this study.
STUDY CONTACT PERSON SUBMITTING FORM
- In the free text field next to “Study Contact Person Submitting Form:” enter the name and contact information for the study team member who is submitting this form.
SHANDS TECHNICAL CODES AND LIST PRICING
- This box can be filled out either by the study team OR Shands ancillary technical PCR contact
- In the free text fields next to “Name of Shands Technical COS Contact:” and “Date COS Form Submitted to Shands:” enter the name and date information pertaining to the request for confirmation of Shands technical CPT and EAP codes and Shands technical list prices respectively.
SHANDS FINANCIAL PLANNING & ANALYSIS TECHNICAL RESEARCH PRICING
- This box can either be filled out by the study team OR Shands Financial Planning and Analysis (FP&A).
- In the free text fields next to “Shands Financial Planning & Analysis Technical Research Pricing:” enter the name and dates information pertaining to the request for confirmation of Shands technical research prices.
UFHP PROFESSIONAL CODES AND PRICING
- This box can either be filled out by the study team OR UFHP professional PCR contact.
- In the free text fields next to “Name of UFHP Professional COS Contact:” and “Date COS Submitted to UFHP:” enter the name and date information pertaining to your request for confirmation of UFHP professional CPT codes and professional list and research prices.
SPECIAL CONSIDERATIONS
In the area with the instructions “Mark any of the special considerations boxes that apply to this study:” enter a capital X in the free text field box to the left of the special consideration. Examples:
X Amendment to PCR pricing issued prior to 09/27/10
X Federally Funded Study
X Pediatric patients
X Adult patients
X Inpatient
X Outpatient
REMINDER
- For budgetary purposes on multi-year studies, plan for a 5% price increase each year. Research rates are estimates. Actual charges will be the rate current on day of service.
SERVICE NAME
- In the free text field under “Service Name” enter the name for the service you need confirmed and priced.
- Note: If you are not sure of the service name, contact the Shands Ancillary location where this service is being administered for this study. Ask them to help determine the correct Service Name required by the study protocol.
- See COS Contacts (GatorLink login required).
- This may involve emailing part of the protocol to the Service Provider so they can help make a determination of the service needed for the study.
- The Shands Ancillary can also help you to determine if the service generates a professional fee, a technical fee, or both.
- If more rows are required, please add more rows via Word 2010 menu Review > Restrict Editing > “Stop Protection” button > copy more rows (do not add data yet), then >”Yes, Start Enforcing” > “OK” (no password) > add row data
ANTICIPATED # OF PATIENTS
- In the free text field under “Anticipated # of Participants” enter the number of anticipated participants that will receive this service while enrolled in the study.
# OF TIMES PER PARTICIPANT
- In the free text field under” # of Times per Participant” enter the number of times this service will be provided to each participant while enrolled in the study.
CPT CODE
- In the free text field under “CPT Code” enter the CPT code for the service you need confirmed and priced.
- Note: If you are not sure of the CPT code, contact the Service Provider and get help to determine the correct service required by the study protocol
- See COS Contacts (GatorLink login required).
- This may involve emailing part of the protocol to the Service Provider so they can help make a determination of the service needed for the study.
EAP CODE
- If you know the current EAP code for this the service, please enter it in the free text field under “EAP Code”. If you are not sure, leave this blank until it has been confirmed by the Shands technical COS contact.
- If the service generates a professional fee through UF Health Physicians (UFHP), your UFHP liaison will fill in the professional list price and research estimate for the service.
TECHNICAL LIST PRICE
- If the service generates a technical fee billed through Shands Financial Services (PFS), the Shands ancillary COS contact will fill in the technical list price for the service.
TECHNICAL RESEARCH RATE ESTIMATE
- If you need the research estimate for this technical service for budgeting purposes after you have received the appropriate technical service list price, forward the COS to Theresa O’Connell OCONTA@shands.ufl.edu in Shands Financial Planning and Analysis. She will fill in the Technical Research Rate Estimate.
PROFESSIONAL LIST PRICE AND RESEARCH RATE ESTIMATE
- If the service generates a professional fee billed through UF Health Physicians (UFHP), the UFHP COS Contact will fill in the professional prices (list and research) for the service.