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Community Engagement >
Rural Health >
Kansas Locum Tenens >
Service Order Form
Address (number & street, city, state, zip):
*OB coverage not available
Billing contact person:
Job contact person:
Work site address (number & street, city, state, zip):
Billing address (number & street, city, state, zip): </textarea>
Locum Tenens period:
Agreement rate (mark all applicable)
* Minimum one day pay required.
* A minimum of six weeks advance notice of the date for locum tenens service is required.
* Payments are due within 2 weeks of completion of coverage. Late payments incur a $25 per day fee.
* An invoice for a $400 KLT fund fee will be sent with the service invoice to be paid to Rural Health.
Note: By submitting this form, you have agreed to be bound by this agreement and this document will be a legally valid agreement.
Preferred e-mail address: (please be specific, i.e: firstname.lastname@example.org)
How did you hear about Kansas Locum Tenens? Please be specific.
To submit, please press
To clear the form and start over, please press
Do you have any questions?
Check out our KLT FAQs.
For more information about how to "Become a Provider" or "Request Service" contact Andrea Ellis at 913-588-1228 or email@example.com.