In Vivo Imaging Core Cancelled Scan Charge Dispute Form

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INSTRUCTIONS: Complete the form below and submit for review. The form must be submitted within 72 hours of disputed charges. The reversal of the charge is granted on a case by case evaluation and can be denied for excessive use.

Email *

PI Name *

Coordinator Name *

Coordinator email *

IIBIS Study ID Number *

Scan Date *

YYYY

Scan Time *

Time

Modality *

MRI at Goodman Hall

PET-CT at Goodman Hall

MRI at R2

PET-CT at R2

Late Cancellation Reason

Describe the effort the study team made to ensure the timely arrival of the study participant: *

Was a tracer or contrast agent wasted?

Yes

A copy of your responses will be emailed to the address you provided.

Submit

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