The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

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This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

Web Request Form

Welcome!

Use this form to request pricing quote for Radiology Services

What happens next?
The Department of Radiology will review your request and develop a cost proposal. Someone from our office will contact you soon.

If you have any questions, please contact us at:

Security -- This questionnaire uses UT Health San Antonio's instance of REDCap. REDCap is a secure web authentication application that is HIPAA compliant. Access is through centralized two factor authentication, all data are encrypted meeting FISMA security standards, physical, network, and computer security is third-party monitored and enforced through the university's Information Assurance Division.

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Radiology Cost Estimate Request Form

Type of Pricing Request:*

* must provide value

Pricing for an Amendment: Complete this form only for the additional services not originally requested.

Request Submitted By:*

* must provide value

Request Point of Contact email:*

* must provide value

Timestamp

Y-M-D

Role	Name	Email	Phone
PI*
Coordinator
Financial Admin
Budget Analyst

UT Dept *

Division

IRB / CTMS #		Funding
Number Subjects		PID
Start Date		Sponsor
Study Title*

Study Plan or Protocol*
Upload: Protocol or Study Plan*
Identify pages pertaining to imaging
Is this the final version or a draft?

Imaging Manual or Guidelines *	Detailed description of imaging required.
Imaging manual available or planned? *

Upload: Imaging Manual

Important - Standard Imaging Procedure is not the same as Standard Care Procedures. The Standard Imaging Procedure justification means that the sponsor has not stipulated how images are captured, relying instead on local imaging practices.

Imaging Capabilities Survey or Questionnaire *	Sponsor document to validate imaging equipment
Do you need Radiology to complete a survey?*

Upload: Imaging Capabilities Survey

Coverage Analysis
Upload the Coverage Analysis

Additional Files
Would you like to upload additional files?

Additional File #1

Additional File #2

Additional File #3

Comments to Radiology

Expand

Which Radiology Services are being requested? *

* must provide value

CT

Nuclear Medicine

Bone Density

MRI

X-rays

Ultrasound

PET and PET/CT

Biopsy & Guidance

Phantom & Setup Scans

Tumor Assessment Reads

Data Transmission/Transfer

Which CT Procedures are being requested?

CT Orbits

CT Face

CT Head & Brain

CT Neck

CT Chest

CT Abdomen

CT Abd & Pelvis

CT Pelvis

CT upper extremity

CT lower extremity

CT Cervical spine

CT Thoracic spine

CT Lumbar spine

CT Other:

CT Contrast?

* must provide value

Which Contrast?

How many "other" CT procedures are needed?

CT Other 1

CT Other 2

CT Other 3

Which Nuclear Med procedures are needed?

MUGA

NM Other:

How many "other" NM procedures are needed?

Nuclear Med Other 1

Nuclear Med Other 2

Radiopharmaceutical for Nuc Med Imaging?

* must provide value

Which Radiopharmaceutical?

Which Bone Density procedures are needed?

Routine (Lumbar/Hip)

Body Composition

Bone Density Other

Which MRI procedures are needed?

MRI Face, Neck, Orbits

MRI Brain

MRI Chest

MRI Abdomen

MRI Pelvis

MRI Breast

MRI Other:

How many "other" MRI procedures are needed?

MRI Other 1

MRI Other 2

MRI Other 3

MRI Other 4

MRI Other 5

MRI Other 6

MRI Contrast?

* must provide value

Which MRI Contrast?

Which X-ray procedures are needed?

X-ray Chest

X-ray Skeletal survey

X-ray Other:

How many "other" x-ray procedures are needed?

X-ray Other 1

X-ray Other 2

X-ray Other 3

X-ray Other 4

X-ray Other 5

X-ray Other 6

X-ray Other 7

Which Ultrasound procedures are needed?

US Abdomen

US Other:

How many "other" US procedures are needed?

US Other 1

US Other 2

Which PET Scan & PET/CT procedures are needed?

FDG

PET Brain

PET Whole Body

PET/CT Skull to mid-thigh

PET Other:

PET Other

Radiopharmaceutical for PET Imaging?

* must provide value

Which Radiopharmaceutical?

Which Biopsy & Guidance procedures are needed?

CT guidance

Biopsy, location may vary

US guidance

Renal biopsy

Lung biopsy

Lymph node (core needle or excisional)

MRI guidance

Biopsy Other:

Biopsy Other:

CT Procedure

Contrast*

Location*

CT Orbits

CT Face

CT Head/Brain

CT Neck

CT Chest

CT Abdomen

CT Abd/Pelvis

CT Pelvis

CT Upper Ext

CT Lower Ext

CT Cervical Spine

CT Thoracic Spine

CT Lumbar Spine

CT ______

CT ______

CT ______

Nuc Med Procedure

Location*

Nuc Med MUGA

Nuc Med ______

Nuc Med ______

Bone Density Procedure

Location*

Bone Density: Whole Body

Bone Density: ______

Bone Density: Routine (Lumbar/Hip)

Bone Density: Body Composition

MRI Procedure

Contrast*

Location*

MRI Face, Neck, Orbits

MRI Brain

MRI Chest

MRI Abdomen

MRI Pelvis

MRI Breast

MRI ______

MRI ______

MRI ______

MRI ______

MRI ______

MRI ______

X-ray Procedure

Views*

Location*

X-ray Chest

X-ray Skeletal survey

X-ray ______

X-ray ______

X-ray ______

X-ray ______

X-ray ______

X-ray ______

X-ray ______

Ultrasound Procedure

Complete/Limited*

Location*

U/S Abdomen

U/S ______

U/S ______

PET Procedure

Location*

PET FDG

PET Brain

PET Whole Body

PET/CT Skull - mid-thigh

PET/CT ______

Biopsy & Guidance

Location*

CT Guidance

Biopsy, location varies

U/S Guidance

Renal Biopsy

Lung Biopsy

Lymph node

(core needle or excisional)

MRI Guidance

______

Phantom Scans
Phantom Scans?*

Upload: Instructions for Phantom Scans

Tumor Assessment Reads
RECIST
CHESSON
Other

Data Transfer Methods
De-identified CD
De-identified FTP
Other

Required Training
Technologist Training?
Radiologist Training?

Technologist Training Information

Radiologist Training Information

Upload: Technologist Training Document

Provide Technician Training URL

Upload: Radiologist Training Document

Provide Radiologist Training URL

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