In Vivo Imaging Core Cancelled Scan Charge Dispute Form
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.
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Email *
PI Name *
Coordinator Name *
Coordinator email *
IIBIS Study ID Number *
Scan Date *
MM
/
DD
/
YYYY
Scan Time *
Time
:
Modality *
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?
A copy of your responses will be emailed to the address you provided.
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