Request KLT Coverage - Service Order Form



Address (number & street, city, state, zip):


*OB coverage not available

Billing contact person:

Telephone number:

Job contact person:

Telephone number:


Work site address (number & street, city, state, zip):


Billing address (number & street, city, state, zip):


Telephone number:

Locum Tenens period:

From: at o'clock a.m. p.m.
To: at o'clock a.m. p.m.


Agreement rate (mark all applicable)

Coverage Rates Units


Daily Rate (per 24hrs)
(prorated in 1/2 day intervals) rate
Holiday pay (per day) $200
Travel Fee (per hour) $30
Estimated Total


* 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:

How did you hear about Kansas Locum Tenens? Please be specific.

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Contact us

Last modified: Jun 20, 2016

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