Get Value Analysis Product Request Form

The Value Analysis Product Request Form is a crucial document for initiating the evaluation of new technologies or devices within UCLA Health System. This guide provides step-by-step instructions on how to effectively complete the form online, ensuring all necessary information is accurately submitted.

Follow the steps to complete the Value Analysis Product Request Form.

1. Press the ‘Get Form’ button to access the Value Analysis Product Request Form and open it in your preferred editor.
2. Begin by filling out Section A, which requires you to indicate the proposed use of the product. Choose the appropriate designation for the product as either standard clinical use or investigational use, ensuring that all additional information, such as IRB approvals, is included if applicable.
3. Proceed to Section B, where you will provide detailed product and manufacturer information. This includes the product name, manufacturer details, and catalog numbers.
4. In Section C, disclose any conflicts of interest by listing all companies related to the product and detailing any financial interests or relationships with those companies.
5. Continue to Section D to describe the product's clinical impact and include information about current in-house products that may perform similar functions. Provide data on projected usage volume and costs.
6. Finalize the form in Section E by obtaining the necessary signatures from the requesting physician, budget-responsible manager, and department chair/chief. Ensure all comments and approvals are properly documented.
7. Once the form is fully completed and signed, attach any supporting documentation, such as manufacturer specifications or research articles that may aid the review process.
8. Return the completed form, along with any required signatures and attachments, to John Yeretsian, the Value Analysis Coordinator, via the specified address.

Complete the Value Analysis Product Request Form online today to ensure your new technology is evaluated effectively.