Service Order Form

Client:

Physician:

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

Specialty:

*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

Totals

Daily Rate (per 24hrs)
(prorated in 1/2 day intervals) rate
$1450
Holiday pay (per day) $200
Travel Fee (per hour) $30
Estimated Total

Notes:


* 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 $300 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.

Client:

By:   

Title:

Date:

Preferred e-mail address:
(please be specific, i.e: tsmith@kumc.edu)

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

To submit, please press

To clear the form and start over, please press

Last modified: Jun 28, 2013
Questions?
Do you have any questions? Check out our KLT FAQs. For more information about "Becoming a Provider" or "Requesting Service" contact Andrea Ellis at 913-588-1228 or aellis2@kumc.edu.
ID=x5543