Participant Payment System Card Order Form

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Required format:

Please use the below form to request new cards for either

KUMC myClinPay or Greenphire ClinCard.

Need Access? Send request to myResearchSupport@kumc.edu

You can find more information about the Payment Systems using the links below:

KUMC-myClinPay

KUMC-Research Administration ClinCard (Greenphire) Program

Request support from:

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SPA

CRA

Don't Know

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Request Type:

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New Study Set-up (SPA)

Established Study (ClinCard request and/or study updates)

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Support Type:

For new study ClinCard setup or other support questions, please email myResearchSupport@kumc.edu.

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ClinCard Request

Add/Remove ClinCard User(s)

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Requestor's Name

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Enter e-mail address to be contacted for questions about this request

A confirmation email will be sent to this address.

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Enter IRB Study Number

Please provide a value.

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Enter IRB Study Number

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PI of Project

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Primary Study Coordinator

Department

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Please provide a grant number. If you do not have a grant number, provide the cost center in addition to one of the following funds - FD004, FD006, FD013 to be charged.

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Attach copy of IRB approval letter

Upload file

Attach copy of approved consent form

Please note this should include payment schedule, max payment that can be made to individual, and IRS reporting language.

Upload file

Payment Schedule File

Please download, complete, and re-attach this list of the scheduled payments that will be made to participants for each study.
Please insert additional rows as needed and provide a separate sheet for each study. This list will appear in the system to make the payment process more efficient for the Study Coordinator.

Attachment:Clincard Payment Schedule.xlsx

User Access Form

Please download, complete, and re-attach this form to add or remove user(s). Insert additional rows as needed (i.e., one user per row).

Attachment:ClinCard User Access Form.xlsx

Attach Payment Schedule

Please re-attach the list of the scheduled payments from the above file.

Upload file

Attach User Access Form

Please re-attach the completed user access form from the above file.

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Upload file

Do you need to request ClinCards?

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Yes

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How many Clincards?

Enter #1-100

Request values preferred as multiples of 10 (e.g. 10, 20, 30)

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Do you need to request myClinPay cards?

All new studies must utilize myClinPay system after 10/5/26

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Yes

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How many myClinPay cards?

Enter #1-100

Request values preferred as multiples of 10 (e.g. 10, 20, 30)

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Would you like to pick up the payment cards or would you like them delivered via Campus Mail?

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Pick up

Campus Mail

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Please enter your campus mail stop:

Estimated 3-5 business days for ClinCard receipt.

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Who will pick up the cards?

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Enter email for card pickup

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What is your requested estimated date and time for card pickup?

Pickup times available are Tuesdays and Thursdays 8:30 am to 12 pm and 1 pm to 4 pm.

M-D-Y H:M

Do you need to add a new or additional user (this includes if you are a new user)?

Yes

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New Site Coordinator - Full Name

New Site Coordinator - Email

Additional Site Coordinator - Full Name

Additional Site Coordinator - Email

Do you need to provide updated IRB approval or consent form?

Current IRB approval must be on file prior to the release of additional ClinCards for the study.

Yes

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Attach copy of IRB approval letter.

Upload file

Attach copy of approved consent form.

Please note this should include payment schedule, max payment that can be made to individual, and IRS reporting language.

Upload file

Additional comments or questions

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Note: As of 7/31/2023 the ClinCard pickup location has changed to the Support Services building.

ClinCards can be picked up Tuesdays and Thursdays 8:30 am to 12 pm and 1 pm to 4 pm. Before pick-up, please let us know via Microsoft Teams or Email that you are coming. We will assist you and open the door to access the RINSTAP office, Rm 120.

Support Services
2100 West 36th Ave
Kansas City, KS 66610
Suite 120

External Phone: 913-945-5945

Internal Phone: 5-5945

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