Service Order Form

Client:

Physician Requesting Service:

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

Specialty Requested:

OB coverage required: Yes No

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.

Notes:


A minimum of six weeks advance notice of the date for locum tenens service is required.

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 Medical Resource? Please be specific.

To submit, please press

To clear the form and start over, please press

Last modified: May 03, 2012
Questions?
For more information about "Becoming a Provider" or "Requesting Service" contact Andrea Ellis at 913-588-1228 or aellis2@kumc.edu.
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