AZ TREVI D8991C00001

For patient reimbursement, we need initial information through this online Portal.

Please Note: Submissions are received and processed during business hours. If a submission is recieved after hours or on a weekend it will be processed the following business day.

The data collected on this portal is solely used for patient expense reimbursement and travel booking purposes. Patient data will not be used otherwise.

Site Number

Example: ES101

Coordinator Email

example@domain.com

Patient Number

Example: ES101-001

Submission Option:

Site Name

Hospital or Clinic Name

Coordinator Name

First NameLast Name

Coordinator Phone

PI Name

First NameLast Name

Is the Subject able to communicate in English?

What is the patient's preferred language?

Is the Subject over 18 years old?

Patient Name

First NameLast Name(s)

Patient Phone

Patient Email

example@example.com

Parent / Guardian Name

First NameLast Name(s)

Parent/ Guardian Email

example@domain.com

Parent / Guardian Phone

Is this the first time you submit a reimbursement or have the bank details changed from last time?

Reimbursement Country

Name as it appears on account

First NameLast Name

IBAN Number

SWIFT Code

Banking fee your Bank may charge for wire transfers

Do you want to fill in the reimbursement form online?

Country

EXPENSE REIMBURSEMENT FORM

*****ALL RECEIPTS MUST BE INCLUDED FOR REIMBURSEMENT*****

Expenses eligible for reimbursement:
· Kilometers to/from site (if personal auto is used), will be reimbursed to the valid mileage rate of the appointment
· Parking charges and tolls
· Taxi fare to/from site
· Meals while traveling

Expenses NOT eligible for reimbursement:
· Alcoholic beverages
· Petrol/gasoline
· Gratuities
· Entertainment items/ medicinal items
· Personal hygiene supplies

Visit date(s) reimbursement

EXPENSES FRANCE € (administrative Power in CV up to 5.000km)

Rows	Quantity
3CV or Less
4 CV
5 CV
6 CV
7 CV or more
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls

TOTAL EXPENSES FRANCE €

EXPENSES SPAIN €

Rows	Quantity
km @ 0.€26/km
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls
Hotel

TOTAL EXPENSES SPAIN €

EXPENSES POLAND €

Rows	Quantity
km @ 1.15 PLN/km
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls
Hotel

TOTAL EXPENSES PLN

EXPENSES BELGIUM

Rows	Quantity
km @ 0.43/km
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls
Hotel

TOTAL EXPENSES BELGIUM

EXPENSES GREECE €

Rows	Quantity
km @ 0.30/km
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls
Hotel

TOTAL EXPENSES GREECE

EXPENSES HUNGARY HUF

Rows	Quantity
km @ 42 HUF/km
Meals (itemized receipt(s) required)
Taxi/Car Service
Parking/Tolls
Hotel

TOTAL EXPENSES HUNGARY

Signature

Date

Upload Files Receipts & Reimbursement Form

Additional Notes and Information

Example: Patient special seating request, preferred travel time, or any restrictions

Solutions Supporting Clinical Trials

Reimbursement Request Portal